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� <br /> � <br /> , <br /> � <br /> Backwater Prevention Device ' <br /> � <br /> � Rebate Program ! <br /> ; <br /> , <br /> For internai Use: Projecl Number. ___ ! <br /> Vend��r Payment Option Form ± <br /> � <br /> Please complete both sides of the form R <br /> � <br /> f <br /> Property Owner Section (please print): ! <br /> �--- — - --- -- — _ ._._ i <br /> _�/r��l>R-nl� - ---- - ---- — � <br /> Property O�vner Namel,/� z � <br /> �1 �UC���:�� i <br /> -- -- � <br /> Properly Address City Slate Zip ! <br /> I <br /> Alternate Mailing Address � � Cily Slate Zip j <br /> `-�j5r 5'.j� •- °( / � _ ; <br /> Phone Email <br /> — , <br /> I, the Property Ov✓ner, requesi to have the Cily of Everett Backwater Prevention Device � <br /> rebale check for the installation referenced at the Property Address be made payable I <br /> lo, and sent to, the Vendor. Qy requa:sting Ihe incentive/rebate check be made payable � <br /> lu the Vendor, I agree to the foilowing: � <br /> i <br /> I <br /> 1. I t���ill not receive a Backwater Prevention Device rebate chc:r,k direcily from lhe ; <br /> Ci�y of Everett. j <br /> 2. Assi�ning payment of the Backwater Prevention Device rehate to ihe Vendor I <br /> does not exempl me from Backwater Prevention Device Rebale Proyram ! <br /> requirements. ' <br /> � <br /> i <br /> I authorize ihe releasc of my rebalr: lo the Vendor lisled on pagc Iwo of Ihis form , <br /> pending approval of the completed Backwaler Prevention Device iebafe packagc by i <br /> lhe City o1 Fverett <br /> ✓�� � ; <br /> —�� i�/_.- /� . . ..� _ �j� � 1/� �_ i <br /> -- — / 1 <br /> S�i�ature o(Property Owner Dafc I <br /> � <br /> I <br /> f'agc 1 of 2 � <br /> Revised 913f2Ut4 � <br /> i <br />