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i <br /> Backwater Prevention bevice Rebate Pror�ra�rn ' <br /> Vendor Paym�nt Option rorm � <br /> Project Number:__ __ (City fo Provide) , <br /> t <br /> I <br /> Please complete both sides of the form � <br /> � <br /> Property Owner Section: � <br /> ---- -- � <br /> Properbj Owner Name: L / /�f E�/ . —��1 1,�� 1 � <br /> ��.)-- i <br /> In�tallation Address: /�! � �= �_ __. � <br /> Ciry: �,�P'��� State: ��/"' Zip:_ � w� _ _ � <br /> � <br /> � <br /> Mailing Address(i(dif(erent}: _____ __ � <br /> I <br /> Gity: State: _Zip: � <br /> � <br /> � � 5 P� � <br /> Email: Phone: (yly 7/,�,�� 2 � <br /> Total Cost to Install Device (Irom contractor invoice): �y__��_3_� 'a� ____.__ i <br /> i <br /> I, the property owner, request to have lhe Ciry of Fvsrett Backvrater Prevention Device rebate check ' <br /> for the installation o(th�device at the above referenced property address be made payable lo, and <br /> sent to, tha vendor specified on tne back of this form. Dy roquesting Ihe rebalo check be made <br /> payable to ihe vendor, I agree to lhe following: <br /> 1. I will not receive a rebate check direcUy from the City of Everetl. � <br /> 2. Assigning paymenl of the rebale to the vendor does nol exempt me irom Backwaler ; <br /> Preventlon Device Rebate Pragram requiremems. ! <br /> --- --- — ...— - ----- ---- _. — � <br /> I authorize the release o(my iebate to lhe vendor listed on the back o(this form pending <br /> approval of the compleled Bockwaler Prevention Device rebate packet by the City of Everett <br /> i <br /> g i <br /> C�_ __ �" G � �Sr I <br /> Signature of Properiy Owner Date �I <br /> { <br /> � <br /> -- -- — -- --- ----- -- � <br /> i <br /> � <br /> , <br /> ; <br /> � <br /> , <br />� - - -- - - <br />