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I <br /> � Backwater Frevention Device Rebate Program ; <br /> Vendor Payment Option Form j <br /> � <br /> � <br /> Project Number: ___ (City fo Vrovide) i <br /> I <br /> I <br /> Piease complete both cides of the form ; <br /> Property Owner Section: <br /> r-- - : <br /> PropertyOwnerNamc:_��C�.�,'� (' `__> `1- L.(��,�,f�---_.��l,l._S'�4'�� ; <br /> InstallationAddress:����_L���_ _ u.� L_____ _ _ __ _ ' <br /> ary: �,-V l �,�.�c�---- state:1�-�—_ziP�\ ��.-��_� <br /> MailingAddress(ild'rllerentJ:________.__ __ _. __ _._____ ; <br /> City:------------ State:--- Z�P'------ � <br /> Email:— ----- ----- Phone:(�' �5��`��_):L9_ <br /> � <br /> Totai Cost lo Install bevice(from contrectorinvoice): $__��yYb�______._ <br /> ; ` <br /> I,Qie properiy owner,request to have the City oi Everett Backwater Prevention Device rebale choa � <br /> for the inslallation of the device al the above rMerenced property address be made payable lo, and ' <br /> sent to.Ihe vondor specifind on Ihe back o(this(orm. 8y reyuesling the rebale check be made <br /> payeble to Ihe vendor, I agree to the following: <br /> 1. I will not receive a rebale check direclly from the City o(Everett. � <br /> 2. Assiyning payment of the rebate to the vendor dor.s not exempt me from Backwator � <br /> Prevenlion Devicc Rebale Program requiremenls, <br /> I <br /> I authorizc the rclease of rny rebatc to thc vendor listed on the back of lhis form pending <br /> approval of ihe rompleted Backwater Prevention Device rebale packel by Uic Cily of Everelt i <br /> I <br /> f_-� �t-��;���. ,t� �)�1.z�4����:� �� - .�1,� -/5" ! <br /> ��- � <br /> SignaWre oi Property O�vner Oate � <br /> � <br /> I <br /> � <br /> I <br /> � <br /> � <br /> 1 <br />