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� <br /> 4i5 117 7956 03:09 59 p m 06-C7-70f i 3�ti � <br /> I <br /> I <br /> � Backwater Prevention Device Rebate I�rogram <br /> Vendor Payment Option Form ` <br /> Praject Numbor. (City fo Provido) � <br /> � <br /> Please complete both sides oF the form � <br />' Property Owner Section: � <br /> I <br /> Pmpetly Owner Name: W`�� �' n��%� I <br /> InslailalionAddress: 1��i,�, ��b�l <br /> ciy: �`�ivL� sta�e: �'�� z�p� �l9'La� i <br /> I <br /> � <br /> Maihng Adtliess;f dMercnlJ: <br /> i <br /> Ci!y: Stale: Zip� � <br /> Email: d5pd�. W�eckCqma��.ceM Ph�ne:(�.$) ah3-�4i4ft,�kxa+5� i <br /> Y onlyl <br /> Talal Cost lo Inslaii Device(Iram mnlractor invoice):S��� Sl" <br /> � <br /> � <br /> I,the pioperty ownet, request to have Ihe C!ry ol Everett Badcwalor Prevenllon Device rebale check ! <br /> for the inetsllation ot the device at Ihe above referenced prapeiry address be made payable lo,and � <br /> ;onl ta,lhe vendor specified on Ihe back of Iliis fortn.By�equesling!he reCale check 6e made i <br /> payab�e lo lhe vendor,I agree to the tollowing: <br /> 1. I will nol recelve a�ebale check duectly(rom the City oi Evetefl. � <br /> 2. Assl9nin9 poyment of ihe rebate to the vendor dce5 no:exempl me Irom OacMvater <br /> Prevenlion Oovice Rebate Program requlremenls. <br /> — � <br /> I aulhorizo thn rcleaso of my rebalo lo Ihe vendor Gsled on Ihe back af this form pending 1 <br /> approval of Ihe compieted Backwater PrevenUon Device rebate packet Cy tho City of Evarett ` <br /> �,C(� /� ; <br /> ---7LG� " +' r�v:�. �"�31 I$ : <br /> Signatum o(Property Owner Dele � <br /> t <br /> I <br /> i <br /> � <br /> I <br /> I <br /> � <br /> I <br />