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_.. . . .__�.._. .--• --� -- ---•----- -..._..�..___ _. . __ ._.. _ ._. � i <br /> � ' � <br /> . ' i <br /> � <br /> ; 'i. <br /> i,.��� � , . ' <br /> � sackwater Prevention device Rebate Program ( <br /> ;. Vendor Payment O�ption Form � <br /> • Project Number. (City to Provide�) <br /> i . <br /> j please complete both sides of the inrm <br /> f <br /> . Property Owner Sectlon: <br /> � . -- ---- <br /> ;.�. �� • � � <br /> ; Property Ownor Name'-- ' j 1(j�L "�"'� -� � ICC� ��_ _ � <br /> � -y� � � --� r--�U <br /> lnstallation Address: � . - 7 __��___ � <br /> � f , <br /> , CNy:i.�{�-+�—Stete. u�__Zip:�1---- <br /> � � I <br /> Maiiing Rddress{d dAferurN) ��'�_ i <br /> � C�y: State: Zp: _ i <br /> � � <br /> � Em�iL• _Phone: ( ) � <br /> � Total Coet to Inetall Oevice(front convaatorinvoh�): 6 ����) � <br /> I <br /> i --- --------�-------- ---- i <br /> I,the property owner, requasl lo heve ihe Ctty of Everett Backwater Prevenlbn DeWCe rebete diec: � <br /> + fot the insfallation o1 the devfc�at the above ralerenced property addresa be mede payabfe fo, snd � <br /> i seM lo, the vendnr spe.cKed on Bie baek cf thie torm. By roQuesting lhe rebete chede Ue made i <br /> I payabla to ihe vendor, I dgreo to lhPi foAowirtg: <br /> � 1. I will not receive a re6ato chtck dlre�clly from lhe Cily of Evarett � <br /> I <br /> ?_. AsxgnhiB paymunt cf Ihe�ubale to the vendor does not exmmpt me(rom Bxkwater � <br /> P�evention Dev�ce Rdtrete Nroguem�eyui�ermJnb � <br /> � . <br /> � <br /> � — -- - - ------------ _--------- — <br /> � I a��thor¢e tt�e release of my 2tmto to Ihe veMlor Irst(rd on ft�e b.�ck oi Ihis torm pending I <br /> � approval of the aomplbtetl �ukw2ter Prowniwn Dawc6 rebste p3¢ket by the I:IIy ot Everetl <br /> I <br /> � ' � J'-/�f`-/J <br /> Signature ot Propedy Ownet Date .� . <br />