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i <br /> �gackwater Prevention Device Rebate Program i <br /> Vendor Payme�t Option Form � <br /> . � <br /> � Praject NumCer _(C�ry ta Provitle) i <br /> i <br /> please complete both sides of lhe form � <br /> PropeRy Owner Section: <br /> � <br /> Propeny0rmerName: �'�/�T�St'"' '�' �L`�� —\n�-- ' <br /> insia�ianon hedres�s,�1-���"�'� �`��ct��� (ryl��`f <br /> C�ly. ��JI�C�/1 Stale: ��J/ � Zip_J a �v I <br /> t.tailing Adaress(iftliHerenq�_��'V`-x" � <br /> CiN'� / Slatc�._ 7.IP�_T_ <br /> Emall�� T t��/�-C. /n 'J� � / /%Y11/,�Ifh`�` �Y� . <br /> Tolal Cosl to Install Device(Irom mnhacfor invc¢e)�.5 y�sJ 3'/�� �� � I`f � <br /> C'7� so v � � <br /> I,Ihe prapony o�+mer,request to have the Gty ol Everetl Baciwater PrevenGon Duvice rebate c�eck i <br /> lor�he�nstaltauon of l7e devlco at I�e ahove ie!erencetl propedy address be made D�Y�ble to,and ' <br /> sonl lo,the vendm spec�f�ea on the���k of In�s larm �y raquesUng Ihe reDalo C�e[i bc matle f <br /> payablc to Ihe ventlor,I agree to Ihc lollowing' . � <br /> 1. I edll not recoiro a raEalC c�eck tllreclly imm I�e City al Euerett. ! <br /> 2. Asslgnlr.g payment o1 tne re�ate lo Ine vendor does nol eeempl mn Imm OaCvvater � <br /> � Prevenlion Device ReGalc Pragram iequiiements. i <br /> r i <br /> II aut�an¢e t�0�o1a350 0l my rCEate to Ihz venCof I�Sled an Uie Oa[k 01 Ihis lo�m pe�U��ng <br /> approval ot lhe campleted Backwatet Prevenlinn Device re6ate packet by Ine Ciry ol Eveioll � <br /> � <br /> I <br /> 0���%vt(��+�.�� `F � �S� ; <br /> � <br /> SignaWre al Pmpetly Oaner Daic , <br /> __ —.— __— _.. _ ___ — I <br /> i <br /> . . _. .. . . .... ._. . . . . . . _ " ' ' ' _ _ . . __. i <br />