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� Backwater Prevention Device Rebate�Program � <br /> rr Vendor�Paymen4 Option fortri ' '�' <br /> I _'. , . . <br /> Project Number. (Ciry fa Pravide) . <br /> . 1 <br /> � <br /> I <br /> iPlease complete both sides of the form I � <br /> IProperty Owner Section: '` . <br /> � — - <br /> IProperty Owner Nama_ J=�F�� � ��6��-L,�}-C� . <br /> ; <br /> i <br /> � installation Address:_ (q/ � 72uG1�=12 I� v� <br /> Citv: E✓; (L�!'1� State: h/f� Zip: ���U / , <br /> � MailingAddress (i(diHerent): __._ . <br /> City: ' : . State: Zip ,:. <br /> � Email: l//Wa/��Cz//I t9 rY1Jnl.fo.K _Phone: (�'?r 5'7/ 'i 6 F� - " . . <br /> � � �o , '; ' . <br /> � Total Cost to Install Device (Irom confractorinvoice): S �}-`I a �"�"' `—" � ' ' ' <br /> i � ' . � : . - . ' . <br /> '� I,the.properly owner, request to have lhe City of Everett Backwater Prevention Device rebate+check� � <br /> � for the installation ot the device at the above referenced property address be made payable to,and. <br /> � sent to, fhe vendor specified on the back of this (orm:By requesting tlie rebate check be made : <br /> ; � payable to the vendor, I agree to the foliowing <br /> i <br /> i 1. I will not reeeive a rebate check directly from the City of Everett. <br /> ; 2. Assigning payment of the rebate to,the vendor does not exempt me from Backwaler <br /> Prevention Device Rebate Program requirements. <br /> � <br /> � <br /> �� I authorize the release of my rebate to.the vendor lisled on the back of this form pending <br /> � approval of lhe completed Backwater Prevention Oevice rebate packel by lhe Cily of Everett <br /> � - �-��-/� <br /> � � / <br /> ' � �` <br /> ! � ��� . <br /> �Signal e of Prope ner Date <br /> I <br /> I � <br /> � <br />