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i <br /> i <br /> � <br /> � �ackwat�r Pr�yention Device Rebat�e Prograrro � <br /> rr � Vendor Payment Option Form j <br /> � <br /> � <br /> Project Nuinber: _(Ciry to Provide) � <br /> { <br /> I <br /> i <br /> Please complete both sides of the form ' <br /> i <br /> Property Owner Section: � <br /> ; <br /> � <br /> _ --- � <br /> , <br /> PropertyOwnerName: `P-'�'� v��sa�� � <br /> 1 <br /> I <br /> Installation Address: t33z v���,�_� � <br /> _ �J�- � <br /> City: r_J���„ State: `+.�� Zip: �y L'01 � <br /> I�iailing Address(if differenf): __ _ <br /> i <br /> Ciry: State: Zip: <br /> i <br /> EmaiC Phone: ( ) � <br /> , <br /> a�, I <br /> Total Cost to Install Device (trom con(raclortnvoice): $ �-�-`-���C Sn� �' <br /> I,the properry owner, requesl to have the City of�verett f3ackvrater Prevention Device rebate check � <br /> for the insiallalion of the device at the abo��e referenced propeity address be made payable to,and � <br /> sent}o,fhe vendor specilied on lhe bnck ot this/orm. �y requeslin�thc rebalc check be made i <br /> payable lo the vecdor, I agrec to the(ollowing; y <br /> t. I tvill nd rer.eive a rebale chr.r,k directly from the City oi Everetf. � <br /> � <br /> 'L. Assigning paymenl of the rebale to the vendor does not exempt rt�e frrnn C��+r.kwater ' <br /> Prevention D�vir.e Rebate I'rogram requiremenls. <br /> I <br /> - --- – -- --- -- — I <br /> I authorize fi�c rr.lease of my rebate to the vendor lisled on the back of lhis form pending <br /> t <br /> approval of the compleled Back�valer Prevention Device rebate packet hy fhe City of Gverett � <br /> �(- ' !— V _. — _� �i� •z���.; _ i <br /> Signature oF Properly Owner bale <br /> 1 <br /> _ ._ --- - -- -- --_'_ ' <br /> � <br />