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i <br /> � <br /> Backwater Prevelntion Device <br /> � Rebate Pr�gram <br /> For internal Use: Prpjec' Numl�er. __ <br /> Vendor �ayment Opt�on Formi <br /> Please complete both sides of the form � <br /> Property Owner Section (piease print): � � <br /> , ; <br /> — -- i , <br /> _ I�,�f��L_;_�-_P_Lsel� � I <br /> Property Owner N�ne � <br /> _l_:��z6Sr�cL����_,_r��!� ySaai-ao,�s�' � <br /> Property Address.' City State Zip <br /> , hni�_�_ _ <br /> Alternate A�lailing Atldress Ciry State Zip <br /> ��--�y1.�5.��L�64�—_—fP rrv l �r�7��1)1L'C.�s_�_,J1�"� 1 <br /> Phone ' Email ' ' <br /> -- — — — 1 <br /> � <br /> I, the Property Ov✓ner, request to have the Cily of[verett 13ackwater Preventioii Device I <br /> rebate check for the inslallation referenced al the Proqerty Address be made payable , <br /> fo, and sent to, the Vendor. By requesting the inceniivelrebate check be made payable I <br /> to the Vendor, I agree to the following: ( <br /> I <br /> � <br /> 1. I ea�iil not receive a Backwater Prevention Device rebale check direr,tly from the <br /> City of [verett. <br /> 2. Assigning payment of lhe BackwatPr Prevention Devir.e rebate to the Vc:ndor { <br /> does not exe:mpt me from Backwater Prevenlion Device Rebale Program I <br /> requirements. , <br /> I autiiorizc the «;leasc of my rc:f�atc to ihe Vendor listed on paye hvo oF this fonn <br /> pending approval o(the completed Ciackwaler Prevention Device rehate package by <br /> the City of Everelt <br /> lp �-� � <br /> _ �'--�- ����.J , ��1,5- <br /> Signafure of Pioperty O�a�ney Da!e' <br /> Pape 1 of 2 <br /> Revised:�312014 <br />