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� <br /> ; <br /> � <br /> �� Backwater Rrevention Dev�ce Rebate {�rogram ; <br /> Vendor Paymeni Option For¢n � <br /> i <br /> Projecl Numbcr: (Cify to Provldo) � <br /> � <br /> 1 <br /> Please complete both sides o9 the form � <br /> � <br /> Property Owner Secfion: ! <br /> I Pruperty0wnerName: Sf�ll�'- IL'-Vj ,��� ��LIGl�1Qc'� ���C(.I� p1.t I� . <br /> i <br /> Instc�IlalionAdaress: Z��3� �IYIt ���" ' <br /> CiIY: L��'d�C�1"�_ Stnte:._I�n..—ZiP:_. � U�i� l � <br /> � <br /> Maiting Address(if dilterentJ� �• V• � �X S �S � ._ i <br /> City:�/��''w✓O� _ Statc: �� Zip:�� Uy � _ � <br /> �mail: M��e,z(� Mw�✓.��(, l!/ aw. W� Phone�(r�� 8S`t G Z-8 4-- <br /> l otal Cost to Install Device(!rom contractor invoice): S �r�� L�v � <br /> _ , <br /> _. _ 1 <br /> i <br /> I,the property o�vner, request lo havo the Clty of Evere;t Backwater Preaentlon Device re6ato check <br /> for the installation of th=device at lhe above referenced property address be made payable to,and <br /> sent to,lhe vendor specifed on Uio back of lhis fortn.By requestiny Ihe rebate check b�mado <br /> payable fo the vendnr, I agree lo the tollou�ing: � <br /> � <br /> 1. I will nol rer.eive a re6at�check dlrecUy irom the City of Everofl. i <br /> 2 Assigning paymont oi the re�ato to the vendor does not exempt mc from Backwater <br /> Prevr.ntion Devir.e Rebate Pwgram requimmonls. ; <br /> i <br /> rI I aulhodr.c lhe rolease of my rebalc to the venAor listod on thc back of this form pending I <br /> Iapproval of Ihe compieted Backwalr,r Prevention Device re6�te packet by the City of Evoretl � <br /> ! <br /> � � <br /> � 3° �� � <br /> � <br /> Signature ol Property Ov.ner Date i <br /> i <br /> - -__ ; <br /> t <br /> � <br /> I <br /> I <br /> , <br /> � <br />