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Backwater Prevention Device Rebate Program i <br /> �. Vendor Pa}rmEnt Option Form i� <br /> Project Number. _ ______ _ _ (Gf}� fo Provide; � <br /> Piease complete both sides of the form <br /> Property Owner Section: <br /> Ji�, <br /> Property Oevner Narrie: ��_`'�T'[ "�''`"`Sil _ I <br /> Installation Address ��3 O 1 5f Sf�'u-� � <br /> City: �:�Lv7� Stale: u � [.ip: 9 �z-° i i <br /> MailingAddress•(i(dif/erenQ: ELS � �46 y� �'�� SL ' <br /> City: �z��t.°"-� State: � /� Zip: �� '�' II <br /> � �. <br /> tmail: �Ci� �-j � �tiK�inif ( "� l�•7`'�ula/��yt"Phone: (la� .�ot ��4'O _ ! <br /> Total Cost to Install Device (lrom r,onlractor invoice): 5 2,��% - � <br /> I, the property owner, request to have the Gty of Everett Backwaler Prevenlion Device rebate check <br /> for the installalion of the device at the a6ove referenced property address be made payable lo, and <br /> sent lo, the ve,ndor specified on the ba�'. of this form By requesling P.�c rebate check be made <br /> payable to the vendor, I agree to the fcllov�ing: <br /> 1 I �vill nol receive a rebale check directly from lhe City of Everelt <br /> 2. Assigning payment of the rebate to lhe vendor does nol exempl me from Backwater <br /> Prevenlion Dewce Rebale Program reyuiremenis. <br /> r---- _ _— _ -- _ . � <br /> I authorize the releaseof my rebale lo lhe vendor iisled on the back of this form pending � <br /> approval o( lhe completed Backwater Prevenhon Device rebale packet by ihe Cily of Everelt I <br /> � <br /> , ,�.a/ ,�/,,�,� <br /> Signature o(Property Owner Dale <br /> -- ---- - --- -- —1 <br />