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i <br /> ! Backwater Prevention Device Rebate Program <br /> iVendor Payment Option F�rm <br /> iProjecl Number: ..__ (City ro ProvideJ <br /> i Please complete both sides of the f�rm <br /> ' Property Owner Section: I <br /> i � — j <br /> I, � � <br /> PropertyOwnerName: �i'J/l/f f"2L7�ri�2 __ { <br /> � InstallationAddress: �o�� /�0�17'� .fT�� <br /> , City: _�(i(��-� State:�_Zip: ��1 � � <br /> i Mailing Address(if diHerent): __���7�itU �L �✓� I� <br /> Ciry:�CJ��i�Ui�l� — State: —��_ _Zip��Zl� _ <br /> � Email: Ci//U}'_P��3��L/ fiU , _��__ _phone: (�So� ( ,�9— fl�'/.�L j <br /> i —� (� � <br /> ; Total Cost to Install Device ((rom coniracfor invoice): S ���'�J �'�� —� <br /> ---- --- — — I <br /> � <br /> ! I, lhe property owner, request to have the Cily of Everett Backwater Provention Device rebale check � <br /> for lhe installalion of the device at the above referenced property address be made payable lo, and <br /> ' sent to, the vendor speci(ied on lhe back of Ihis form. By reyuesting �he rebate check be made <br /> i payable to �he vendor, I a�ree lo ihe following: I <br /> 1. I �vill not receive a rebale check direcUy from the City of[veretL � <br /> 2. Assigning payment o(the rebate to the vendor does nol exempt me from Backwaler 1 <br /> Prevenfion Device Rebate Program requirements. <br /> I I aulhorize the release of my rehate to the vendor listed on the back of this form pending I <br /> approval of ihe compieted Back�valer ?revention Device rebale packet by lhe City o([veretl I <br /> ���� � _�-�S 1,5� <br /> Signature of PropeAy Owner Date <br /> I <br />