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i <br /> � <br /> i <br /> � Backwater Prevention Devic:e Rebate Program � <br /> Vendor Payment Option Form ! <br /> � <br /> Project Number, (CIty to Provide) � <br /> I <br /> Please complete both sides of the form i <br /> i <br /> Property Owner Section: , : <br /> ; <br /> � <br /> Property Owner Name:���n��`=i� ����'� � <br /> � <br /> i <br /> Installalioq Address: •� -I'�Z �c.<Cr��i�- � L^P«�!�J � <br /> City: �=-/L�C�41C% State: �l/^ Zip: ��7J �� � <br /> � <br /> Mailing Address(if diHerent): � <br /> City. _ State: Zip; i <br /> . <br /> Email: 1 ��Phone: (��- �D p , ' <br /> � <br /> Tolal Cost lo Install Device (Irom r.onfracforinvnicef. 3 � <br /> i <br /> � <br /> I, the properly owner, request to have the Ciry of Everett Backwater Ptevention Device rebale check � <br /> for lhe installation of the devicc at the above referenr.ad property address be made payable to, and <br /> sent lo,the vondor specified on Ihe back of this lorm. By requesling lhe re6ate check be made � <br /> payable to the vendor, I agree to Iho following: i <br /> I <br /> 1. I will not receive a rebalo check direclly(rom the City of Everetl. � <br /> 2. Assignin� payment of the rebato lo the vendor does not ezempt me from Backwaler � <br /> Prevention Device Rebate Pmgram requiremenls. � <br /> � <br /> i <br /> I aulhorize lhe release of my rebate to Ihe vendor listed on ihe back of this form pending j <br /> approvai oF the crornpleled Backwater Prevention Device rebate packel by Ihe City ol Everelt ' <br /> _J J � <br /> % � � � <br /> i ; <br /> / i <br /> < G'�-�{�/ �'1�,/ �, �t;%z�tc+F;1Cr� ; <br /> Siynature of Property Owper � <br /> � Uale <br /> -- -- ` <br /> ----- -- --- ----- --- l <br /> I <br /> 1 <br /> I <br />