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� Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Pro)r.ct Number _ _ (City fo Provide) <br /> Please completc both sides of the form <br /> Property Owner Section: <br /> PropertyOwnerName: �L�� ___._� __ <br /> �nstailalion Address: _ ��V.y_-_�,��1 LC�I�''V� ___ <br /> CitY _ �U�.�'�� State �� r\ _ Lip.—_l�o ��. _ <br /> �laihny AJdress (ildilferent): . - _ - _ _ _ <br /> Cdy Slalr ---- Zip. -- — - <br /> Emad _ "�}��SU�J��1. �[31�— Phonc ��J�a�_ 32� (. <br /> � Total Cosl to Install Devicr. (/rom c.oniractor invoir.e) + �,��q _ __ <br /> �_ _ - ___ -- <br /> I I, the property owner, requesl lo have U�e City of Everelt Bar,kwaler Preven�ion Device rrbate chrck <br /> (or the inslallation o(the dewr,e at Ihe above refcrencr.d property address Ge madc payible to, and <br /> sent lo, ihe vendor sper,ihed on lhe bar.k of llns form By requesling 1he rebale check be made <br /> payable lo Ihe vcndor, I agree to the follnwmg <br /> 1 1 will not iec�civr: a u�b,ite check duer,tly from�he Cily ol[verc�tt <br /> 2 Assigning payment ul Ihc robatr,to the vendor dnes �o�exiarnp� me irom Backwaler <br /> Prevenlion Uevice Rebale Pmqram reqwrements- <br /> - �- -- -� --- - _ . . -- - - � <br /> I �udhorizre thu relr.ase nf my reb.de to Ihr, vendor listed on ihe bir,k of Ihis form pending � <br /> .ipproval of the cornpleted Rar,k�vater Prevenhon I)nvir.e rrhaic par,ket hy ihe Gity ol EvereU �� <br /> I <br /> �.�C� OCv I(�J I,� � <br /> Signaturf. o(Pruperty Owner D��P <br /> I . ----- �--� ------ .. _. _ . _ .. - . ��. <br />