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(N� Backwater Prevention Device Rebate Program <br /> �n Vendor Payme�it Option Form <br /> °ro;=ct r;umber. _ __ _ (Cir,to Prov;da) <br /> Plea�e cornplefe i�oii� sicies of tiie fiorm <br /> Property Owner Section: <br /> ----- — — -— --------------- __� <br /> /> / `� � <br /> Proper,y Ov:ner Name: U�tL- b- C7Z� C L�,)-t,J i <br /> installation Address:_ /Ov/ ilZyi ��vE I I <br /> IC,ry:�yZG—r gtate: I.✓l.'#— ZiP:_��"1_Z� — I <br /> �� f�^,ailing Nddress (ii dlffereni); /�d�/o¢, L1 y �� S i. /.L� � ! <br /> i <br /> IGity:��2�L-iZ�--� Stale: I,u Zip:���Z� _ <br /> ERiBi�: � ��=(_r'rlc/tSc�.��,1.�sv�. �r7, w7� _ u } PhOf1B: (��(�o� y3�_ r/JjU <br /> IJ <br /> Tota, Cost to Inslall Devlce ((rom ccnh'actorinvoiceJ: $ <br /> � <br /> I. U�e proper,y ott�ner, request to have t'�e Cdy of Everett Backwater Prevention �evice �ebate check <br /> for tnr. Inslallation of lhe device at the above referenced property address bo made oayablo to, and <br /> senl to, the vendor specified on the back of thls form. By requestlny the rebat� checn be mada <br /> r.��able to the vendor, I agree to the folbe�ing: <br /> 1. I r�ill not receive a rebate chech direr.11y (wm Ihe Ciiy o(Fveretl. <br /> 2. Assigning paymenl af tho rebate to the vendor doos not exempt me frorn [3acka�ater <br /> Prevenllon De�qce Rebatc Program requlrements. <br /> iI authorize ihe reloaso of my reba(e fo fhe vendor Ifsted on the back of(his form pending � <br /> a��proval o(the completed Backwale�Preventlon Dovir,e rebat� packet by the City of Everelt I <br /> � / � <br /> , /�- <br /> ) i <br /> i �l i _ J�� 7d/d" I <br /> _ _ '_ ______ _ __J <br /> Sign tu e f roperly O�vner Dale <br /> U <br /> _ ___ , <br />