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_ _ _ _,. � �,_.l <br /> � -. � <br /> , ��,,,,,, .. <br /> Backwat�r Prev��ntion Device Rebate Program , <br /> Vendo!� Payment Option Form <br /> � <br /> Project Number._ __ (Cify to Provide) <br /> , I <br /> i Please complete both sides of the form I <br /> � Property Owner Sectian: <br /> PropertyOwnerName:�0.r�L Lr�✓i�cr" � <br /> InstallalionAddress: IO2� Ro��Cet-Q��e� N'✓� { <br /> � City: �vP<r��" State. 4��" _Zip: 9 g20� � <br /> I <br /> I <br /> Mailing Address (i(diHerenQ: <br /> City: State: Zip: <br /> � Email: _Phone: (�S)3yS 3708' <br /> ITolal Cost to Install Device(from confrector invoice): $ 3779 l7 � <br /> I <br /> I I,the property o�mer, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at the above referenced propeAy address be made payable to, and <br /> sent to,lhe vendor specified on the back ot this form. By requesting lhe rebale check be made <br /> payable to the vendor, 1 agree to the follov�ing: <br /> 1. I will not receive a rebale check directly from the City of Everett. <br /> � 2. Assigning paymenl of the rebate to lhe vendor does not exempt me from Backwater <br /> jPrevention Device Rebate Program requirements. <br /> � --- --- --- — ---- -- <br /> � I authorize the release of my rebate to the vendor tisted on the back of this fonn pending <br /> I approval of the completed Backwater Prevention Device rebale packel by the City of Evereti <br /> � <br /> i <br /> ', <br /> ,��..�- G�.,.�i �y��{/Y <br /> Signature of Property Owner Date <br /> � <br /> i <br /> I 1 <br /> � � <br />