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i <br /> i <br /> i <br /> i <br /> � Backwater Prevention Device Rebate Program , <br /> Vendor Payment Option Forrn � <br /> i <br /> Project Number. (City fo ProvideJ � <br /> � <br /> Please complete both sides of the form � <br /> Property Owner Section: ' <br /> � <br /> — — - � <br /> Property Owner Namc:�L� ��� i <br /> ��.,¢... <br /> inslallation Address: �,�� � /�t.7.n� .�Sa . � <br /> i <br /> Cily: �l� State: �.v+�" Z,p: �� �/ � <br /> �' ; <br /> Mailing Address (i(diKerent): �� 'l%��-v { <br /> City / State' — Zip: I ; <br /> Email _LJ_l�`?c � f.�.,,P�4� Phone' l'-"7�;.3D 3 - 'r"���J,� � <br /> i <br /> Total Cos�to Install Device (Irom contractorim�oice). 5 2.�0 0_ dQ � <br /> t <br /> i <br /> -- —' -- � <br /> I,ihe pwperty owner, request ro have the City ol Evereq Backvdater Prevention Device rebate check I <br /> (or the installation ot Ihe device al the above referenced properly address be made payaUle to, and � <br /> seol to,the vendor sper.ified on the back of this form. By requesting the rebate check be made <br /> payable to Ihe vendor, I agree ro Ihe following: � <br /> 1. I wlt not recerve a rebale check direclly(rom Ihe Cdy of EveretL � <br /> 2 �ssigning payment of the rebalc to the vendor does nol exempl me (ran Dackwater <br /> Prevenlion Device Rebate Program requiremenls. <br /> i <br /> i <br /> .. -_' -_ ' _ i <br /> II authorize the release of my rebate to Ihe vendor listed on the back o(this form pending � <br /> � approval of the compicted �ackwater Prevenlion Device rebale packet by lhe City ot EvereU j <br /> t <br /> � <br /> � �p � � <br /> — ��,.� �a?�X(� �'�,�� J=��—/.s� ' <br /> r--,�—. <br /> � <br /> SignaWre ot Property Owncr Dale i <br /> � <br /> - — —-- � <br /> + <br /> i <br /> 1 <br /> i <br /> i <br /> I <br />