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i <br /> � <br /> Backwater Prevention Device Rebate Program � <br /> Vendor Payment Option Form : <br /> ; <br /> � <br /> Pro�ect Number (Ciry fo Provide) � <br /> i�iCdSB �JfiiaiZi@ vOii1 SIGeS Oi iilC i0i117 : <br /> 1 <br /> Property Owner Section: <br /> —� ; <br /> --- /L I,� <br /> i ?ropCrty O�'+ner Name. ,�j�[�.t_�_�C�11�� <br /> i Installation Address. _�L�_t_�.U[�.�i—.�1LC'1��� F <br /> ICitY �v�.l_C�l-- State: —(��.—�Z�P�g-.�,��- <br /> I� ylailing Adtlress (il dUfe�ent). , __ <br /> ICdy: — State. _ Zi�'--- — I . <br /> Email: K�r�L� �l.�c.+_����n�1c��nt-c—. Pno�e (4.75_2�_-]S66 , <br /> 1'otal Cost to Inslall Device (Irom contrecfor invoiceJ: S 1_ ��� Ul,_��P�"S '4Y`Y I ; <br /> ' -----� 2�-19�! • 5 rj� <br /> �---------- <br /> �, Q�e property owner, request to have the City of EvereU Backv:ater Prevenhon Device rebate check t <br /> for the installaUon of the dev,ce at the above ref2renced oroperty address be made payable to, and � <br /> sent to, thc vendor speci(ied on lhe 6ack o(Ihis form 8y requesling lhe rebate check be made ; <br /> payable lo the vendor, I agree lo the following. <br /> t I �vdl not receive a rebate check duer,lly from the Crty ot Everett ; <br /> ? �ssignmg paymenl of the rebate to thc vendor does not exempt me trom Backwaler ; <br /> Prevention Device Rebale Pwgram requiremenls � <br /> i <br /> I authorrze the release o(nry rebate to Ihe vendor hsted on Ih� back ol lhis form pending I <br /> approval ot the completed Backwater Prevenhon Oevice rebate packe[ by the City o( Everelt <br /> I ' <br /> � <br /> ��/ ____�/!�G�� i <br /> ,t, �z/-r���s--- � <br /> Signature oi property Owner �—' — __ Date j <br /> _------ --� ; <br /> _ ------- —---- � <br /> ; <br /> � <br />