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. i <br /> � <br /> , Backwater Prevention Device Rebate Program I <br /> � � Vencior µ�.yment Option Form I <br /> �.—�_"" <br /> �. Proiecl Number: (Cify fo ProvldoJ <br /> �, � <br /> � Please complete both sides of the form ' <br /> i <br /> � Properry Owner Sectlon: <br /> i ` ' n � ` �� nIr ' <br /> I PropeAy Owner Nemo: V�.� 1' t� �� `"� �'�(' . �%r I r`l: � ��'.�_k' f l � <br /> � Instellallon Address� � �'� S� � (,`�� � r��''(� . <br /> i ' Clly: �l l�� I ��Stato:,� {� 1 21P: �� � ��.� , i <br /> ( Mafung Address (i(dr/ferenQ: I <br /> I U <br /> I Ciry: (�l.'�I l � \ _ state: li t�' Zip: �( .�C� _ <br /> � Emall: �f'�/i l ^(Y . (� C ���� ( C�r�C�,� fli � �� (.j� 75� 1_��f / ; <br /> Phone: <br /> 9 J � <br /> � Tolal Cost to Install Devlce (from contrectorinvorr.eJ: 5 !� �U� <br /> I 1 <br /> I, the praperry awner, request to have lho Clty of Everetl Badcwater PrcvoMion Device rebele check <br /> j t�r the inst3ilation of the device at the 3bove referenced proporty addreu be made payable to, and <br /> � sent tn, Uic vendnr specllleA on the hack of thls fam. By request(ng the rebate chack be mada � � <br /> � peya6lc to the cendnr, I uprm lo Ihe lollowinp: , <br /> 1. I wlll nol rocaive a rehate chack directly from Ihe Cily of Everell. <br /> i 2. Assigning puymunt uf Uie rebulu lu lhe venJur dous nul excinpl me lrom Bdckwalnr <br /> � Prevenlion Devico Rob�le Proarem roqulreme�ls-_� - �, <br /> � I Aulhorize qia relaese of my rabala lo U�e venJur,lialnJ on Ihe beck of�hia furm pendhi,y <br /> I <br /> approvnl of Ihe compietad Bnckwuter Preventlnn Device rebnte por.kel by tha City at Evnrett <br /> i <br /> t <br /> ����� ���'��?Q � � � • ( '' � <br /> SlgnaWre o(Property Owner Ootc � <br /> �. - ------ - ---- � <br /> � i <br /> � <br /> . <br /> i.- - --- ------ -_ _ _ �---- -- -------- _ _ - -------- ---•�-• -- -- <br />