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i <br /> . � <br /> � <br /> f;� Backwater Preven4ion Device FZebate Program i <br /> � Vendor Payment Option Form 3 <br /> i <br /> Project Number. __ (City to Provrde) <br /> � <br /> ; <br /> Pieasp comptete both sides of the fortn . ' <br /> � <br /> ; <br /> , Property Owner Section: i <br /> • , _ 5 <br /> . _ <br /> PropertyOwnerName � ` lr��'�C.ut:. �{, y )�1cr��vJ <br /> Installalion Address � �l C+ � ^ �r��nc� {=�-�- __ I <br /> City:��l-QfY—I � _Stale:��__Zip:__��Z� I ♦ <br /> Mailing Address Q/di/ferenQ: � � � � J �7`S�S S l (���r'— ___ <br /> Cily t- �l,r,c���� State: �Jf•-t _zip:�Z?_ 3 <br /> FinaiCLC�Ii�����..,u��_�fr.l1�'12C�% �C>�'n Phone (3�)��3� 30� ' ; <br /> Tolal Cost to InStail Device(!rom confracfor invoice): £ _ ' <br /> � � j <br /> I.�he prqperty owner, ir.ques�lo havFe the Gity ot Gveretl Backvaater Prevenlion Devir.e rebate check � <br /> lor Ihe insiallalion of the device al the above relerencecf property adtlress be maAe payable to, and � <br /> sent lo, the vendor specihed on Ihe back of Ihis(omt By reyues�ing the rebate check be made i <br /> payable to the vendor;i agrce lo Ihe lo�lowing - � <br /> � � .. . . _ . _ . . . ; <br /> 1 1 wdl no�receme a �ebate check directly from Ihe City-iif 6veietL � " � j <br /> 2. nssigning paymenl of fhr iebatc to Ihe vr.ndo�does not exempl me fmm Dackwalcr � <br /> Prevenllon Uevice Rebate Progiam requirernenls <br /> I ��uthonm Ihe iclease ot my icbate to the vendor listed on Ihe back o(this fnrrn pentlmg <br /> appiuval of the completed f3ackwaler('revenlion llevice rebate packet by Ihe City of Everett ; <br /> � I <br /> /� , i <br /> � � i' ; <br /> _� _� <br /> J ��� �� 'L�, 7 �r-� <br /> t i n.,, 'r n n,r ( wn i�i ' Date <br /> Si_ �a i -f I { ty J <br /> - _ -- _ . - _ I <br /> � <br /> i <br />