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,_._ . _ . . . - - - - .. _i _ . _ _ .._... --- <br /> ' � <br /> , , <br /> ' �Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. j (City to Provida) <br /> ; <br /> � <br /> Please complete both sides of the form <br /> Aroparty Owner Section: <br /> , - � <br /> ' � <br /> Property Owner Name: Chuck Steinber�er <br /> � Installation Address: 1528 Rucker Ave <br /> Ciry: Everett State: WA Zip:48201 <br /> Mailing Rddress(if diHemntJ: <br /> City: � Stale: iLP:--- <br /> Email: chuckstelnberser@aol.com Phone: (a75) 739-4346 � <br /> i ; <br /> Total Cost to Install f1EvlCe(/rnm tlonlrectorinvoiCe): y�l��. <br /> � <br /> � , <br /> i, Ihe property owner, requesi to have the City of Everett Backwalor p��eMion Devic�rebate check <br /> � tor fhe installalion of the device at the above ielerenced property eddress be made peyable to, and <br /> sent to, Ihe ventlor specified on;lhe back of this form. By requesting tho rebate check be mede <br /> payable Io the vendor, 1 agree to the fo�lowing� <br /> 1. I wlll not u:c:efve a reDate check directly from the City ot Everett. � <br /> 2. Asslgning payment of the rehate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requlremoMa. <br /> I authorize thc release of my icbale to the vendor listed on the back of this tofln punding <br /> approval o(the complefed[3ackwalur Prevention bevlce rebate packet by the Ciry ot Everett <br /> I <br /> � ���f � - `/L z" 1��1 J <br /> / ��.--- <br /> � Signature ot Proparty Owncr Date <br /> . .. � � . <br /> . . � <br /> � � <br />