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Pro;ecl Number. <br />Backwater Prevention Device Rebate Program <br />Vendor Payment pption Form <br />—._____ IGty fo P�ovrde) <br />��_ <br />rie&Se CuiiiNicie uUiil 31ia@9 ui <br />ii"ie fuilii <br />Property Owner Section: <br />Prcperty Oovner Naine M <br />U <br />� Ins�allahon Apdra55: __�_5�5 ��-f�'1 C r----- � .,-- _ <br />1� -- in/ nJ <br />CiIY: _�j_�/Y�1_�L_— S(a�e: _4 �'�i--- ZiP � � Zi� �-- <br />— ^ �_ � �----- <br />; ivlalliny Address (ii diflerenq �%� � {����(� <br />� Ciiy ` { .._�,-=�'7_"���/� -- . <br />� �' �b�--__ Sle'6� � _ Zip:_---[�---0 r�i 'y�--r�-- <br />' Email hP O�(' �it� P ( I�� �P�`I <br />--�����._L�_ hone 41a <br />; Tolai Cost lo Insfall Device (bom contracrorinvoir.e)� S_ `Z•r�� t' "Y"G�, �( ___ _ <br />!. the pro�erty o�rmer, requesl to have tne City of Everzti BacRwafar Preveniion DevirE reoa(e check <br />(or Ihe installa[ion ui Ihe device al Ihe a6ove re(zrenced propary address be made payable lo. and <br />senl to, Ihe vendor sozcifietl on the back of (nis torm. 6y requesling the rebale check be made <br />payable lo the vendor. I aoree to Ihe followiny; <br />1 I vrill no! recei��e a reba�a check dire�ily (rom the Cily oi Everet! <br />2 Nssiyning payment of the rebale to Iha vendor dn>s not exern�t me from Backwaler <br />P:e��enlion Device RebaleProgram requiremants. <br />--- — <br />--- — -- ----- -- <br />I aulhorize the releasc ol my rebaie Io the venUor listed on Ihe back of this (orm pending <br />approval of Ihe cnmpleted packwaler Prevenlion pewce rabale pack�; by ihe Cily o� Ev_rell <br />� <br />_ .—'---- —_ �, 1 , --�/ <br />,x " � e _' __ - VJU / 5 <br />Si�nat e ui Pro�ehy Owner <br />Date <br />