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i <br />------ — - -- � <br />Backwater Preventio�� Qevice Reb�te h�ogram .. ;� <br />Vendor Payment Option Form �; <br />Projecl Number: <br />(City (o Piovide) <br />Please comglete both sides of the form <br />Prop�rty Owner Section: <br />.. ;; <br />� <br />�I <br />j� <br />�i <br />i <br />i <br />ii <br />� <br />i <br />, <br />_ J . . <br />Fropert�� Owner Name:�"(_M (1.�Y�. �, Z1 �'�`�`�=g � �~ <br />InstallaGonAddress 2� (� v�U�-'LV� l �1 �/-- _'___ <br />City: �"U�-T state: �� 7.ip: y d Z- L' � _ <br />Mailing �ddress (i/ diNerent): _ <br />City: _ Slate: _ ^ Zip; <br />Email: Phone: ( ) <br />'�3 c'� <br />Tolal Cosl to Install Device (lrom contractorinvoice): $ ��� �� � � <br />I 1 <br />!i <br />i� <br />!: <br />� . , . . . . . , i <br />I, the property owner, mquestlo have lhe City of Everett Backwater Prevention Device rebate check <br />for tha installalion of the device at the apove referenc; d properiy address be made payable to, t�nd , <br />sent to, fhe vendor specified on lhe back of ihis form. By requesting the rebate check be made � <br />payable b lhe vendor, 1 ag�ee lo thc tollowing: <br />1. I will nat receive a rebale check diredly from tho City of Everett. <br />?_. Assfgning payment of the rebate lo Ihe vendor daes nol exempt me trom Backwaler <br />Prevention Device Rebale Program requirements. <br />I aulhonze ihr. rMcasc of rny rebale to the vendor listed on tt e back of this form pending <br />approval oi the wrnpleted Backwaler Prevenlion Device rebat�: par,kel by Ihe City of Everelt <br />�1 �)��_ -- <br />Sig �Iur�GPfoperty Owner <br />Uale <br />. � -1 __�— , <br />