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;:.:; <br /> � :u�. . <br /> .�;: . <br /> � Backwater Preventlon Device Rebate Program <br /> �Vendor Payment Option Form <br /> Pra)ect Number.� (Ctty fo Piovlde) � 1 <br /> I <br /> � <br /> Please complele both sides of the fortn i <br /> Property Owner Section: � <br /> I <br /> �uon I <br /> PropertyOw�erName: �� '�'""'��� <br /> Instellatlon Address: �531 ���' ��- � � <br /> I <br /> cuy: L�.bR3� s�a�e: �` ziv: t��'I i <br /> i <br /> Mailing Address(ildfRorantf: I <br /> CttY= State: Z'ip: I <br /> Emau: ��•�@(�G1oo1 tt4A-G�-• Phon::( � ���'v I <br /> I <br /> Total Coal to I�.+fall Device(hom unlractor MvdceJ:S I <br /> I <br /> I,tM propeKy owner,reque9110 havc Ihe Cily of Everell Backwater Prevention Oevice reEata chxk � <br /> for the indalletbn af IAe devlce al Ihe a6ove referenoed property eddress ba made payaWe to,and <br /> 62M l0,IAC VE/1dGf 6p8tifiEd Ofl UIB Da[k Of MI6 Mflll.By RQUlSIifl9 UM flD2fB Ch6Ck DS TddB � <br /> parable to the vendor,I agree to the Iollowinp: <br /> 1. i wilt not rsceiva a rebete chack diroclry hom Ihe City of EveretL <br /> ' 2, Assignirg paymenl of Ihe rebate lo IAe vendor tloes notexempt me from Badcwater � <br /> PnvenUon Device Rebale Propram requiremenls. i <br /> I <br /> � <br /> f authoriu the release oi my rebaie to the vendor Ilsted on Ne bxk oF I�Is tam pendlnp '� <br /> approval af the wmpleted 8ackwaler Ptevenlion Devlee rebale packet by!iw City of Everett <br /> -'���� l�l z� � � <br /> i <br /> SlgnaWre otPropeAy Owner Oate <br />