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i . .,.,._� � _ � <br /> , .,.. ,. ,: � . . <br /> Backwater Pte�ention Device Rebate Program ' <br /> �i���`�' �Vendo� Payment Option Form <br /> -'b'�` _ ;:R. <br /> :;�;:.;: <br /> � Project Number. >:rt's:-' •- • __ (City fo Provide) <br /> � , � .��4��.�. ... . . <br /> . n3.:tl. �. <br /> ,o� <br /> i ". <br /> i � ,Pfease complete both sides of the form <br /> i • <br /> , <br /> j Property Owner Section: , <br /> � — l <br /> ; Property Owner Name: .���. : � G� T� _L � <br /> I Installation Address:�_?J d K 'l � / �' ✓ �l l. <br /> I � L <br /> Cit i—V� �� 7 f State:�ZiP� � <br /> y� _ <br /> � <br /> fvlailing AdCress (i(diKerenQ: <br /> l City: _ State: Zip:_ <br /> I <br /> i Email: Phone: ( ) <br /> I l �/ <br /> i Total Cost to Install Device (/rom �rontractorinvoice)� S o?�U! -�C1 <br /> I, the property owner, request to have the City of Everett Backwater Prevenlion Device rebale check <br /> for the installation of the device at the above reterenced property address be made payable to, and <br /> sent to, the vendor specified on the back of lhis form. By requesting the rebate check be made <br /> payable to the vendor, I agme to the following: <br /> i 1. I will not recei've a rebate check directly from the Cily of Everett. <br /> i 2. Assigning payment ot the rebate to the vendor does not exempt me from Backwater <br /> � Prevention Device Rebate Program requirements. <br /> I aulhorize lhe release o( my rebale to lhe vendor listed on the back of this torm pending <br /> approval of the completed Backwater Prevenlion Device rebate packet by the City of Evereft <br /> � � � ��� � ; � <br /> Signalure of Property O�vner Date <br /> � <br />