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� <br /> Mar 13 IS 07: 14p P' 1 <br /> Backwater Prevention Dovice Rebate Program <br /> Vendoc:Payment Opti�n �orm <br /> �rol��t NunDer. --•-•-- ---•��,,ty tr.Provide) <br /> Pleasa so�npieYe.boti� si�es oF the iorm <br /> Nropetty.Owner Section: <br /> _....._...,_.}......__._.....,". _ ..._...__._---__._---�----.........:..... ..._..__..._......_ <br /> , __.—...__..____, <br /> � <br /> ; �q � <br /> Frepert O�lm.er��m9:��I'�v� Vt Q cL e ._-----.._ i <br /> ; ___...---...._..----�— <br /> � �nstaiiaGon A.ua;assr , (73 1 R U C(c��-- � ' <br /> ; /' _._._- —y-�-...._..._._. � <br /> _._.__...._.._.__.._.__..---- <br /> � City:.l%.^_✓.� _ SI3te;.�U--_-........2iP�_.._�_ �'�o r --___ ; <br /> i h.�aiiing Adaiass(itdlEarenp:_� -- , <br /> —..._..___._.......__ _.........__.. <br /> ; ' : . <br /> � Cil . � ^' , , �.:-�. ., ' ' <br /> . _ . � <br /> Y'.__.�.... ap+h.........---"---..._2ip. .� : <br /> ; . �� � .. . � . ... .__._.._.._ . <br /> � Einm1::;�0.L�/83U �. Yti1Ct1I . CfiN1 Phons' ��r �-������ ; � <br /> .-- --_-.{--..!_ �.._..,�._..........__-- <br /> i - , . ` _ .. 1—._ <br /> ; roiai cest;o inF�e7+����+ce�nc,�i cc�r�a���•n.o��o�:S �Z `�l �l 1 . 5 i <br /> �,!he property or;re.r,req�:sst t,?bavs tho City ot Eve�ett 6nckv:sler Piavantlan Deei:e;�nbete check <br /> for 1he inslallaUon.of IL•a Jevlc�;tt the abovz r�'erenced proreHy aC�ress"a�naoe payaE!e to.anh <br /> se�s?10,tho vendd-spe:atied on:ne tacK oiihls�orm.ay raguesting ihe reoa'.�check hs mede <br /> p�yebte to tl�e v:ndor. I egree le Iha(ol!ow�ng <br /> _ i�siil nqt rr�caiv:a rabaie check tliiecty�from U,e��City o(Ev�reit�� <br /> %. i+�'i�n��ne paymeqf�of tna rcbBtydU(hr Vantic(deas n018Rehi,r..i mz(rcm 8sckrra;er <br /> P:evefl;lon De�9ca Rebale?ro9r0in rqu;ren�enls <br /> �: I a�hen,�e:he rAlenca a�m� e.b�t��to ihe �aricl��i s,ed on 25e��ack of tn+s forr.�penGl^9 � I <br /> �i,�pra�r;l o'tha rom!�Iated Bac'nw�ter Prav2phon p,v_o f.abe;e p7cket b:;he Gr.y of Evareti I <br /> i <br /> � <br /> . � r � <br /> ____ ___ , ��s- . <br /> �==- - <br /> Signe �BGf PlOP9fty OS'11"a� . . CdIC . <br /> I <br /> � <br /> I <br /> I <br /> I <br />