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. .. ,:; .� - i <br />. _ _ <br />Backwater Prevention.Device Reti�tp Program _:.: <br />; Vendor;Payment Option.Fo�rn � <br />_ . -� , , ;.: , . _ � <br />;: <br />Projeet Number ` .� (Gty to P�oWde) : <br />. , , <br />' • Please corinple�e l�th s�des oflhe fofln ' '..� �: , <br />' ' • � <br />' • Property Owner Section• I <br />. ' <br />prope�tyOwnefNeme ��IyiA-s-� �• %1��`-��NN�2 - <br />.. . ... .,. : . _ ., �. <br />Installation Address ' �a Co%5y �/�_ � . <br />�;ry: �v�n.�� r s,a�: ,�iJ�_ Zv� :��3 za � � <br />Mailing Address (il dilleienf): . <br />��: _ � gtate: ` � ZP- <br />��,�y� 2/ i3 2..- <br />Emeit � j,.«k'�-w:LQ.�.ri►iF�./ �•Lon.— �Pho�e (�)(/) �� <br />_ � <br />To{al Cost to lnslall De'vioe �(/rom oon6acfor invo/ce): 3��' ���.� a - <br />_'. 1,1he.propeAy owne► request tn have Slie CRy oi Everefl Badcwatar Prevenbon Devloe eGate check . <br />for the:inst�ation dtne devlce � aes above refeiei�ced ProPe�tY address be made pa� able tq ane <br />� . sent lo; the venclor epectlled on the badc oF ttds tomn. By reVue�!!91� iebe6e d�eek be maEe . <br />I m the foUowalO. ' � <br />' p'ayatile bo Ute veridor i�rae . _ <br />' 7. . I wlll trot teoeSve a rebata chede diradly Gcim the'Clty of Everetf: - � . <br />2. i�as�9��!9 PaYrt�ent of !he tebafe lo. lhe vertdar does not exdnpt mC lrom Badcwotcr.:.•. ''' <br />�. ; PrAveMlon De�ioe Rebate Propram reQuiremen�. . . <br />. ,. <br />; ,r- . . . . .. , . <br />1 aulftotae the re0eaae �ol�my reDate to tlie ven0or flsted an the ba�ck oT th�s form pe�Aing... . <br />. . aPPr'oval af fhe compietcd 8ackwafer Piwontion Devloe rebate pacicet by,tlx� City.of Ev�dt . .' ,. <br />_ `� 22.�� ' <br />, . <br />.` SYgi��we of Prr�perty,Owr�er ' ,, ,, . Date .; _ • <br />. ; . _;, ti, <br />_ ,- <br />, ,;s <br />r <br />;`: .�•'. ,.. �''.' ,:- . . <br />..::� . � . .. . . r <br />-;..' : <br />, . <br />