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�� .�(^' r.�'�..'�.�C-• ' <br /> r . :.: .�{C .14 . , i � . <br /> . �Mti•' ;]k'L " �1��; .. <br /> �s. <br /> t:. <br /> � , <br /> � Eackwater Prevention Device Rebate Program <br /> ��� Vendor Payment Option Form <br /> � Project Number. _, (City to Provide) <br /> i = <br /> i Flease complete both sides of the form <br /> i <br /> I <br /> Property Owner Section: �; <br /> I, Property Owner Name: Yeia/ �3e�-z . <br /> � InstallalionAddress: NG� �u[if-tr <br /> City: �'v��cs� Stale: W�' Zip:_�'2a/ <br /> Mailing Address(i(dilferant): <br /> I <br /> City: State: Zip: <br /> i EmaiC Phone: (�) �S� ���� <br /> � . . _. <br /> � Total Cost to Install Device (from coniractor invoice): 5 � �C•— <br /> � I, lhe property owner, request to have ihe Ciry of Everetl Backwater Prevention Device rebate check <br /> for the inslallalion of the device at the above referenced property address be made payable to, and <br /> j sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to lhe vendor, I agree to the following: I <br /> i 1. I will not receive a rebale check directly from the City oi Everett. <br /> 2. Assigning payment of Ihe rebale to Uie vendor does nol exempt me trom Backwater <br /> � Prevenlion Devicc Rebale Program requirements. <br /> �, i <br /> � — <br /> � I authorize the release of my rebate lo the vendor listed on ihe back of this form pending <br /> approval of ihe compleled Backwater Prcvention Device rebate packet by the City o(Everelt <br /> � <br /> � �-/y/�� <br /> � <br /> Signature of Property Owner Date <br /> � <br /> � <br /> i <br /> � I <br /> I i <br /> I - – -- – - <br />