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G� �E2/ ETJ <br />,_; <br />Backwater Prevention Device <br />Rebate Program <br />For intcrnal Usr.� ?roj�ct Number: __._ <br />Vendor Payment Option Form <br />Please completc both sides of the form <br />Property Owner Section (please print): <br />-- -----� — - — � - - - � <br />2U ll �-_ � � _-�-�_ � 5 - -- - - <br />Property Q�:�ner tJarne <br />23�r, ���;_��w��-.M,�-S_�vc��—rr �.� Q�2�i�3�z1 <br />Prnperty Rddress Ciry Sta•,e Z�� <br />� 7�0l.1t= <br />� _----- - -- --- -------- — — - - --- - <br />I•Alleinate I�lailing Addiess Ci(y State 7ip <br />� Q.2�-2S2-Q>� � - -- h.`�_�L����4�0 � hv'�~m�t � _c.z��r� <br />- C----- <br />Phonu Email <br />I, the Property Owner, reyuest to have the City of [verett E3ackvdater Preventian Devicc <br />rebate check for the installation referenced al the Property Address be made payable <br />to, and sent to, the Vendor. l3y requesting the incentiva/rebate check be made payablr <br />to'h�-� Vendor, I agree lo the follo�•diny' <br />1 I will not receive a I3ackw��ler P�evention Uevice rehate check directiy (rom the. <br />City of Ev��retl <br />? i�;signmg paynient uf ihe Bar.kv;at�r Prevention Devir,e rebale to thr. Vendor <br />rio��s nol exempt me from B;�r.k�vater Preven�ion Device Rebate Program <br />iequirements. <br />I authnrize ihe r��lease n` nry r��bate� �o Ihe Vend��r lisled nn �i;�qe hvo of this fo;�m <br />pendmg approval of lhe coinpleted Backw��tei f'iet�un�ion [)evic«� nal�at�� p�r,kage by <br />ihe City o( [vercll <br />, = Q=�( --�i�� �d� � --- <br />Siunatu�c nlPropi:ily O::n��1r <br />ma,2�►I= l �, �1�e� s _ <br />n�,r�� <br />Fayc 1 nf Z <br />�levisad 5?i:; :�J i �1 <br />