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<br /> � Backwater Prevention Device Rebate Program
<br /> , � a�T Vendor Payment Option Form
<br /> � � � ,�. (Citydo Providel :.
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<br /> � ' Pfease com;�lete both "si�les of the form > �?�
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<br /> i ProFierty Owner'Section: ' ; ; ,
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<br /> i , PrcPerty Owner Name:�p�V�2 f} /17/3U�P_E�tiJ ; S%CVL-J:J$ �' �
<br /> ��=, InstallationAddress: I// /–�/ Si �-: , ' � ; ; ' �
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<br /> �� J city: ���77 -- .State: Lc�y4—'---Z'p:_ , 9 �'LC�•% ' ' ' .
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<br /> `, . Mailing Address (ildi(ferent):_
<br /> Cdv — _ Slate. Zip: —
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<br /> Emad:., � Phone: ( ) � �
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<br /> Total Cost to Install Device (from contractor invoiceJ: S �
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<br /> I, the property owner, request to hav"a'the City of Everett Backwater PraJenGon Device re6ate check
<br /> i (or the installation of the device at the a6ove referenced property address be made payable to, and ,�
<br /> � sent to, Ihe vendor specified on the back,of lhis form. By requesting the reba'e check be made (
<br /> � 'payable to the vendor, I agree to the following:
<br /> � ' �
<br /> � . 1 .'I will not rzceive a rebale check di�ectly from the City oi Everett. ' �, �= �
<br /> ; 2 ��Assigning;payment of the rebate to the vendo� does not exempt me from Bac.kwater
<br /> ' , Prevenlion Device Ret�ate Proa!am reyuirements. i ; �
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<br /> t � � I authorize the release o: my rebate to the,vendor listed on lhe back of.this form pending �, , f
<br /> � •e •r., approvel bf the completed Backwater Prevention DeJice rebate packeC by the Ciry of Everett�
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