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� <br /> i <br /> } <br /> / i <br /> r � <br /> � Backwater Prevention Device Rebate Prograim ` <br /> Vendor Payment Option Form <br /> � <br /> ProjeG Number. (Clry to Pmvldn) � <br /> i <br /> I <br /> Piease compie:e bo:n sides nf tt►e form i <br /> � <br /> Property Owner Section: <br /> � <br /> P Y �L�xL��NJ' --._ � i <br /> pro en OwnerName: <br /> � Ir�talla�ss: � -� � I�--� — ! <br /> � �m:,��,��—s��:��p:��o L � <br /> , <br /> Maliing Address(�YdNkrent):, � <br /> � <br /> CitY:� State: Zip;— <br /> Emall;�'��('n,�,� q Al I,�_Ptrone:��i��.� � <br /> rl d � <br /> Tota!Cost to Inslali bevice(Irom comrecrorinvolce):5��ql� �7� _T <br /> : <br /> I,the pmperty owner,request ro have the City of Everett Beekvrdter Prevention Dev(ce rebate c�eck ; <br /> fOr Iha insialletlon of the device at thp above reterenced propeAy eddree6 be ma0e payable to.and <br /> sent to,lhe vendor spedfied on the back of this torm,By requesting the rebale check be mada <br /> pey8ble lo the vendor,l agree to the tollovring: <br /> 1. I w1i1 not recelve a tabale check directty from thC Ctry oF Evefett. <br /> 2. AssigNnp payment of tha rehale to 1ne vF r�or tloes�rot exempt me from 8a:kwater � <br /> PreveMlon�evfee ReDate Progrem�eqwremenls. • ! <br /> I euthorize the release ot my rebale to the vendar Iisted on the beck ot this fartn pending ! <br /> epproval of the complete BaGewaler Preventian Devlce rebxte peckef 0y tne Clty oi Everett <br /> Tl..-. ) I`J' j <br /> Sign ture E Prcpe Owner D te � <br /> i <br /> � <br /> � <br /> i <br /> � <br /> i <br />