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Backwater Prevention Device <br />Rebate Program <br />For internal Use: Prc�ecl Numbc:�r <br />Venclor Payment Option Forr�i <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />r— -- --- -- -- — ---- <br />__ l� O 4. n �4 � ts �•� <br />F'ropeiiy Oc,���n7c�]; N me (� r/ I <br />.-.. �`-31_ylil{�`J4' �l-/Z,iY ��l2iP_�7 ��10 <br />Property Address � City State Zip <br />I Altemat� �viailing Address City State Zip <br />i _ <br />I Phone Email <br />�---- <br />------ -- — � <br />I, Ihe Property Owner, reyuest to have the Ciry of Evereit [3ack��,�ater Prevention De��ic^ <br />iebate check `or the ins(allation referenced at the Property Address be made payable <br />tc�, and sEmt to, the Vendor. By requesting the incentive/ret;ate r.heck be made payable <br />�o the Vendor, I agre� to the (ollowing. <br />1 I v;ill not receive a f��r,ktvater Prevention Devi�e rebate che�k directly frorn lhc <br />Cily o( Everetl. <br />' �ssignina pa��ment of thr� Ci,3ck�vater I'revention Device rebate to the \/endor <br />do�=:s not ex�anipl ntc fi�im fla�:k�vat�r i'revr.ntion Di;vicc Flef�ate Progi;ini <br />rc�.�uiroments <br />I aulhari�e ihe relcase o( n�y rebat�: tn the Vendor listed on �it�ye tti�o of ihis (orm <br />pendin� approv�l o( the coinpleted 13ockwalei Piev��ntu>n I)evice r�bale par.kago by <br />Ute City of Everetl <br />'1 / <br />- � , <br />,I <br />=-- _ -�^— - _`��— ----- --- <br />rSign� ,ure ol Properly O�vn�r �' <br />Revised 91'3i7_01-0 <br />_�- L � -�'�-- <br />�Date .. <br />1'age 1 of'l. <br />