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�^%Q� Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> F�o�ect Nurnbr,r _-- _ ----- (Crty!o Provide) <br /> Please complete both sides of the form <br /> F'roperty Owner Section: <br /> �— -— <br /> -- -- -- — — , <br /> Prope�fy Ovmer Name l�(j1I �IC��� ' <br /> --- ____ _ _- ---- <br /> Installalmn Address p� ��-Y__ ���----------_-_- <br /> ���y _t412-r�-- s���P s,.•t� .-- z�u 4d�_o3 - -__._.�_ I <br /> � <br /> Mai6ngAddress(ddillerentf __ ._. ____. _ I <br /> City ---- - - __-- State: _ Zip ---- - <br /> EmaiC ------ . -------- -- Phone• (L���j�uv-_�00�1 I <br /> _ _-- <br /> Total Cos�lo Insfall Devlce (Irom conhacloi invoicey S ____ �U �1'_ �� __..- <br /> -�-- -- <br /> � <br /> I, Ihe property owne�, requr.st to have the Cdy of Fveretl Backwater PrevenUon Devir.e rr.bate chr.cF <br /> for the installation oi the dr.v�ce at the abovr, relerenced properly address be made payabl�to, and <br /> sent to, the vendor specified un the back of this form By reyuesliny Ihe rebale dieck be maAe <br /> payable �o the vendor, I agrr.e In the following <br /> 1 I will not receivr, n rebote check direclly Irom the City of Everr.tt <br /> 2 Assiyning payment of Ihe rr.batc to the venAor does not r_zempt me Irom 8ac.kwaler <br /> Prdvenlion Device Rebale Program reqwremenis. <br /> i - - - _—__ _ -- - - <br /> I authonm thc relr.ase nf my reb:dc lo ihr. venAor luled on Ihe hack of�his fnnn pr.nding <br /> approval of the completed Backwaler PirvenUon Device mbalr, packel by the Cdy u1 Lverelt <br /> � <br /> �� . l� 3 ._t,J1 �_ <br /> Signature of Property Owner Dale , <br /> - - - - - - - - - -- -- � <br />