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. � <br /> , <br /> ' ' S ,��5`�+�,'^ �. .J`.�'�. SAa�cs•s_^,S}ti.�.�''�-r-'aT4L p�t^,.�.`,�F`" . . <br /> �`�y,.' _� - 1 . <br /> . ._ 1 <br /> _ i <br /> i i <br /> . . � . � � .- � � ' .. . . � <br /> i <br /> i <br /> i <br /> � <br /> -Backwater Prevention Devicr, ^ebate Program ; <br /> � Wendor Paytnent Option Form : <br /> � <br /> , <br /> , <br /> Project Number. __ _(City to Provide) ' <br /> i <br /> I <br /> i <br /> � <br /> Please complete both sides of the form : ' , <br /> Property Owner Section: I <br /> i ��� ' <br /> Propeity O�•✓ner Name: C"YEr� '� r�0-rV rz�ra Li C�'f Yi 2:--F-��"� . <br /> i <br /> � Installation Address � �0 Z �'m�°'r� '�"��' � <br /> ( cny: Cv�v�l-4- sia�� W/k z�P: °i�a-�� � '� i <br /> , j i <br /> � h9ailing AAdress (il diflerent): ]I � <br /> � <br /> City: State __Z�p' I � <br /> EmaiC ��r1.r�� QaO���O ��LG�mffLS I-. n C� _Phone�. �ZS) �23--1��� li ! <br /> � Total Cosl to Install Device (lrom contraclorinvoice): 5 3�� •`'�U � j <br /> , <br /> � <br /> i <br /> ----- ---—------- � <br /> —----- — - i <br /> L lhe pwperty ovmer, request to have lhe City of Everelt Dackv�pler Pretenlion Dr_vice rebale check ; <br /> for the installation o(the devicz at ihr above re(erenced property addrer, be made payable to, and ° <br /> senl lo, ihe vendor speclf�ed on the back of this form. 13y requesting the rebate check be made ; <br /> , <br /> pay�+ble to the vendnr, I ayree to Ihe follo.viny - � <br /> ` <br /> 1. I evili not receive a rebate check directly from the Cily of EveretL % <br /> 2. Assigning payrnenl af the rebate to the vendor does not exetnpt me from Backwater . � <br /> � <br /> Prevenlion Device Rebate Proyram requiremenls i <br /> -- _ ___ _--- --- ----- ---- � <br /> r — � <br /> I1 aulhorize lhe relr.ase o(my rebale lo Ihe vendor hsted on the back ot�his (orm pending , <br /> i <br /> approval ol Ihe compteled [3ackwater PreveNion Device rebale pacl:et by Ilie City of [veretl � � <br /> I <br /> i <br /> i <br /> ����Yt%r..�� �` (7��-C1.��-i-C�_�C'trc.�- E�1� �J �(o ��J i <br /> T i <br /> Signature of P�operty Ovrner Date <br /> — ---� I <br /> �------------ .. , 1 <br /> � --�------ '------ - � I <br /> I <br /> . � � . . " . . _ . . . .. . .. . . . . 1 <br /> t <br /> i <br />