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. ' <br /> ; <br /> Backwater P�evention Device Rebate Program ; <br /> ,r Vendor �a,yment Option Form ' <br /> i <br /> . � <br /> Project Number: (City to ProvideJ ! <br /> i <br /> Please complete both sides uf the form j <br /> � <br /> Property Owner Section: ! <br /> - ; <br /> �-Q � (i / ; <br /> Property Owner Name:�,��,(i._g�-/;,� �) �,,,r� s�,� <br /> G, i <br /> installalion Address: o�7(i � ��<�/ � � <br /> / i <br /> City: �.,�no.L�(. State: ��/t , ZiP: g���� i <br /> i <br /> Mailing Address (if diHerentJ: j <br /> , <br /> City: State: Zip: � <br /> I <br /> Email: Phone: ( ) 3 <br /> Total Cost to Instail Device (lrom confrectorinvoice): $��l '�� i <br /> i <br /> i <br /> I, the property owner, request to have lhe City of Ever�tt Backwaler Prevention Device rebate check � <br /> tor the installation of the device at the above referenced property address be made payabie to, and � <br /> sent to, the vendor specified on the back of this form. By requesting the rebate check be made i <br /> payable to lhe vendor, I agree tu the following: ' <br /> i <br /> 1. I will not receive a rebate check directly from the City of Everett. ; <br /> i <br /> 2. Assigning payment of!he rebate to the vendor does not exempt me from Backwater ! <br /> Prevention Device Rebate Program requirements. ' <br /> i <br /> i <br /> -------- � <br /> ���� � <br /> I aut� horize the release of my rebate to the vendor lisled on the back of this form pendi�.i <br /> approval of the completed Backwater Prevention Device rebate packet by ihe City of a � <br /> l <br /> � <br /> 1 <br /> i <br /> // I i. _ A� V � � • L v '�' I <br /> JC�.p��.'Ff <br /> Signature of Property Ovmer Date ; <br /> � <br /> _ i <br /> I <br /> � <br /> � <br /> i <br />