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i <br /> � <br /> Backwater Prevention Device Rebate F'rogram <br /> d Vendor Payment Option Form � <br /> � <br /> Pro;ecl Number. __ __ (Cit}�fo ProvideJ , <br /> Please complete both sides of the form � <br /> i <br /> Property Owner Section: � <br /> -- – — - , , <br /> � /-�� /� , i <br /> � Property Ovmer Name: ��[tl_+�C'/1 LJ u-7� �c�/� , <br /> IInstallation Address: 1 �. � S �.�1,��� �T-'s - _ a <br /> !I City: lyJe3�,p_-Lf' State: \.r�/A . Zip:�f,�j_/ I <br /> �viailing Address (if different): _ � <br /> ' Ciry: State: _ Zip:_ <br /> ' Email: bu^ � tt-(!?�C',L�uS�t�it('1���n � . �`v'�"F'hone: (c'� .5'�u1 - 1 �f-� Zj � <br /> � <br /> Total Cost to Install Device (lrom contracforinvoice): $ '� .fcc <br /> i <br /> i,lhe properly owner, request�o have the Ci��- of Everelt Backu✓ater Prevention Dewce rebate check <br /> for the in;tallalion of ihe devfce at lhe above referenced propeRy address be made payable to, and <br /> scnt to, lhe vendor specified on the back of this form. By requesting the reLale check be made � <br /> payable to the��endor, I agree �o the followiny: <br /> I vdill not receive a rebale check directly from the City oi Lverelt. ' <br /> ?. Nssigning payment of Ihe rebate to the vendor does not exempl me from E3ackv✓ater <br /> Prevention Device kebate Program requirements. ' <br /> � <br /> — --- - -- - — I <br /> I authorize Ihe reiease of my rebate to the vendar listed on the back of this form pending <br /> approval of lhe cornpleled Backwater Prevention Device rebate packet by the Ciry of[verelt <br /> I <br /> � <br /> � <br /> I --�<�-j.L�-�C-G��!'i��/....J J�oZ� '�Cj �� I <br /> Signature of Properiy Oemer Date <br /> i <br /> � <br />