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i <br /> � <br /> Backwater Prevention Device Rebate Program j <br /> Vendor Payrnent Option Form ; <br /> i <br /> , <br /> Project Number (City fo Provide) � <br /> r <br /> ?iease con�piete botii sides of 4iie form � <br /> Property Owner Section; i <br /> Property Owner Name: Ryan and Jiil Bysegger � <br /> i <br /> Installation Address: 2079 Colby Av;:nue j <br /> i <br /> Ciry: Fverett State: WA Zip: 98221 ' <br /> { <br /> Malling Address(d dilfeienf): E <br /> City: Slale: Zip: 1 <br /> EmaiC jebysegger@gmaiLcom Phone: (206)704-1838 � <br /> 1 <br /> Total Cost to Install Oevice{from contrecforinvoice;:5 2,499.59 � <br /> !! <br /> E <br /> l <br /> I, the property owner, request lo have the City o(Everett Backwaler Prevention Device rebate check i <br /> lor the installation ot the device at the above referenced property address be made payable to,and � <br /> sent to,the vendor specified on lhe back of Ihis iorm. By requesling the rebate check be made t <br /> payahle lo the vendor, I agree lo Ihe foliowing: ! <br /> { <br /> 1. I will nol receive a rebate check direc0y (rom the City of Everelt. i <br /> 2. Assigning payment ol the rebate to Ihe vendor does not exempt me from Backwater I <br /> Prevention Device Rebale Program requiremenls. ' <br /> 1 <br /> I aulhonze the release of my rebate to the vendor listed c,i the back of Ihis form pending � <br /> approvai of the comp�eted Dackwater PreveNion Device rebate packei by the Ciry of Everett ' <br /> I <br /> , <br /> '� ✓ 2 �5 ! <br /> � <br /> � <br /> Signafure ot P ert ner Date ; <br /> `% � <br /> ; <br /> ; <br />