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r.�,- - - - _.___ _�, <br /> ,. <br /> , . <br /> � <br /> � . �^�a�Backwater Prevention Device Rebate Pr�gram <br /> • � Vendor Payment Option Form <br /> { <br /> � <br /> ; Project Number: (City to Provide) ' <br /> f <br /> ' Please complete both sides of the form � <br /> I I <br /> � Property Owner Sectlon: + <br /> � / -- 1 <br /> i Property Cwner Name: �C� ��1��• f' /� - -- .- _-�— � <br /> . � Z� � , <br /> ' InstallnlionAddrOss: <br /> ' Cily:���Q� State: i,� Zip: �fJ <br /> i. Mailing Address(if drHerenq: ����y�l�� <br /> � City' State: _Zip: <br /> � <br /> � Emall: Pnone: ( ) � _ ( <br /> n j <br /> � Total Cost to Install Device(from cantrec7or MvoiceJt 8_���� I <br /> � <br /> ( . � <br /> ; I, tho propeAy owner, request to heve lhe City of Everotl Backwater Prevention DeNce rebate check � <br /> 1 for the installatlon o(the device at lhe above referencetl oroperty address be made payable4o, and <br /> � senl to, the vendor specitied on the back oi�his 1ortn. ey requesting the rebate check be made <br /> I' payablo to lho vondor, I �grca fo the fotiowing• <br /> � <br /> � 1. I w�ll not receive a rebate check direcily hom the City of Everett. <br /> � � 'L. Assigning poyment oi the rebate tc the vendor dces not exempt me from Backwater <br /> Prevention Device Rebat9 Program requirements. � <br /> � �-� �_._._---- <br /> � I authorizo the release ot my rebate to the vendor listed on the back of this fonn pending <br /> iapprovei of the completed Backwator Prevenlion Dnvice robate packet by the Cily of Everett <br /> � , ' � . <br /> ' . ��v� ' , ���/"J�� <br /> I �— _ <br /> i , Signaturo of Property O�mer Date <br /> � , <br /> c • <br /> I • � ' . . ' . . , . . <br /> !.._._.�---- ._'.� .�.......____-'---- -� _.. M� _�.-�- •--•._.�-, <br />