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i <br /> i <br /> I <br /> � Backwater Prevention Device Rebate Program � <br /> r Vendor Paymen+ nptier Form <br /> Proj�ct Numbcr: ____(City fo Provide) � <br /> i <br /> � <br /> Please complete both sides of the form � <br /> Property Owner Section: ; <br /> - - __ _ � _ <br /> Pro.^erty Oemcr Namc: �/Q_ �� � w ` ; <br /> _,_L f ' <br /> Installation Address: _ � r _�'����� � i <br /> ' City: (.�Y�/----- State:. �----Z�p' — I <br /> Uailing dress (d dille�ent): __ : <br /> Cily: ��G� Stale.!��__7_iP: ; <br /> - ------- 1���.3 � , �Z.� � <br /> Email: Phone: ! <br /> Total Cosl to Instail Device (lrom cont�aCtor invoiCeJ�$_�� r- � I <br /> I <br /> I,the property owner, request ro have the Ciry of Everett Backv�ater Prevention Device rebate check <br /> for the installalion of Ihe dev�ce at the above reierenced property address be made payable to, ar�+ . <br /> sent to, ihe vendor specitied on the back ot Ihis lorm. By requesting lhe rebate check be made ' <br /> payable to the vendor, I agrec to lhe lollowing: <br /> 1. I ivill not ieceive a rebale check direc.11y Oam the Ciry ol EveretL ; <br /> ?. llssigning paymeni of the rebale to the vendor does not exempt me from Backwater i <br /> Prevr.nhon Device Rebate Program requiremenls. � <br /> I <br /> �- - -- ---- ._ _ --- _ � <br /> � i authonze the rclease ot my rcbale lo�he vendor listed on the back of this lo�m pending � <br /> approval of the completed H�ckwater Prevm�ion Device rebnte packet by the City o1 Fveret� <br /> ; �� /�' ��, - ��5�"j ; <br /> � Sign e ol Praperty Owncr Date I <br /> i <br /> _ -- -- -- — __ — ------' ` <br /> i <br />