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�Backwater P�re�^ention Revice Rebate l�rogram <br />,, Uendor Pa}��s�e^rt Option Form <br />�.PrnjecWumUer:�.. �� � . �--{CltytoProvid�) . � � . . <br />Please complete bath sid�:s of the form <br />Property Owner Section: <br />ProPertYUwnet,Name:__.Jr�S�j�: 'J"'�7LC�5('N <br />Installation Address. �� /T ��-- _ <br />r�r�t z, 9 E, z`�� <br />�ity: . ti' � i�� --. State: P' <br />.30//�, � m-�t N� <br />Alailing Address (i( diffefenlJ: �/ F L � z <br />��ry .S��CWb✓l.'�1�----/sta,e: (i✓'%i _ziP:_- — <br />� � �GGiC(� C.'�/�1,!'i2 ��� �Phone: Q� '� �� / '���� <br />EmaiL �� <br />�, - � � ,�! <br />Total Cost to Install Oevice (Irom contracfor invoice): £___�.�P�= <br />�------� , ---� --�— . . <br />I, ihr.property oivner, request to have Ux: City o( Fveretl Dack��ater Prevention Device robate check <br />for lhe installation of tho device at the abnve referon�ed propeM1y address hc mad� paYable to, and <br />sent lo, the vendor specified'on the back of lhis (ortn. BS' requesliny �e rehale check ta madc <br />payable lo the vendor, I agree lo lhe foVuwing � � <br />1, � wilt not�re�ive a rebato check direclly fr�m Ihe City o( EverelL � <br />2. Assigning paymenl of the rebate to the vendor does nol exompt me from Back�vater <br />prevenlion Device Hebale Proyram requiromonls. . <br />I authorizc iho release of my rebate to Ihe venAor listed on tha bnck of Ihis form ponding <br />approval of lhe com��leted BacAv�alor Prevenlion Devlca rebale pachel by the City of Everett <br />, � <br />%� � " j' . /0/%' �� <br />-� --- --- <br />---------- <br />Dato <br />Signature o( Property Ovmer � . � , � <br />'� <br />n <br />