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OS/27/2015 S:Oi P� FAS 4259748488++ y � vuvoiovvi � <br /> k <br /> � ; <br /> a <br /> I <br /> � g2�kwater Prevention Device Rebate Program ' <br /> Vendor Payment Option Forrn j <br /> � <br /> Project Number: , � <br /> (Cit� to Provide) ' <br /> i <br /> I <br /> ?iease co�iplete both sides o�the form <br /> �roperty �wnerSection: j <br /> ��peRy Owner Name: y��,-., ` � i <br /> iIns;allation Address: !Ct05 � i f <br /> - f Cit : c _ ; <br /> I Y 5�1��,fC_� 3tete: I,�7�- _Zip: �i �r1CJ( I <br /> iMaihngAddress.(iidrt/erevt):. � . ; <br /> I C'ty; =:' - State: v � . . : <br /> Ir : ..: . P�" � <br /> � ':• EmaiP _._ :, .. _� , �.. . . PhoOe:.(2cY}�rr!-I�r> . .. .. . � <br /> - <br /> -. ... � � � . _ . _. � .. <br /> � Total Cost to Ihstall Device(fiom oontrdcror lnvaceJ:S � <br /> : <br /> ; <br /> , <br /> I;.fhepropsdy ottiner, requesc to heve V;a CI!y nf Everett Back�valer Preventiqn DevlrP rebat=clieck I � <br /> ror tho inslsllatlon of che device at ihe aboi�e rete[enced property address De made payable to,antl <br /> sent to,lhe v�ndor specifled on the back of lhis (cmi:By requesting the rebatecheck.be.made � <br /> payahle 10 tiie vendoi„I,aqoee to Ihe following: ' <br /> '4., 1 vnlF not�ceive a-tehate chBck dire�tly irori the City Of Evefetl. � <br /> _ ; <br /> 2: Assigning paymenCof ths rebate tc the vendor aoes not ezerrpt mp trom Backwater ; <br /> PreJOntion �evice RebatePiopram requirements.. <br /> _. _ - . I <br /> .__ ; <br /> I I authorize the reiease cCmy rebple lo thn vendor)�sted.on the 6ack o`thls foim.pendiny �. � <br /> approval oi the comp::ted Bar.kv,ater f�revention bevice rebate packe� by the City of Gvorett � ' <br /> ; <br /> _ . , L <br /> _��7��17 ,r.c�-. n.n.n � d��.L7�/S _ � :. ' . . i <br /> Sfgnatu of Pro�lerty Ov��er : • Date ' <br /> L1 : � ; <br /> ._ <br /> . , <br /> .��. _ ; <br /> _�. , <br /> . : _ , . . _ . � . <br /> __ _ <br /> . <br /> : <br /> _ _ .. . <br /> � <br /> _ . .. _ . <br /> . . . . . <br /> : _ <br /> . _ .:. � <br /> ; <br /> _ . <br /> , <br /> . , , <br /> --�-_ _ _ . � <br /> , _ . _ <br /> � <br /> ; <br /> � <br /> � <br />