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52712015 SCAN0011.JPG ' <br /> ,.. . . _.. . . _ .. . _._.. . ._ ._. .._- ._ . .._-�___ '___. _ . ...__._� _ . . . . . .. _._ _ . .. <br /> I <br /> !> <br /> ( :.'/,''. . <br /> nl-: � <br /> i � <br /> ; � Backwater Prevention Device Retiate Program i <br /> ; Vendor Payment Optio.t�:�.orm � , <br /> ; ! ; <br /> , <br /> Praject Numbzr:___ (C/tyto Provldo) � <br /> t <br /> ' � <br /> ' i <br /> Please compiete both sides of the form ; � <br /> Property Owner Section: ! ' <br /> ' '---�- - - — /� i <br /> , • PropertyOwnerName: ���I IT • CrdS1'�C��O ' � i � <br /> �-- -� . <br /> ' I Instellallon Addresx _ �7�q___��jYY7�.��__ _ i <br /> ' �iry' -�i��----Siate:�n�_�_Zip:_ 9t�o��� _ � <br /> Mailing Address(il dilferenf): -��/1� =Vi/ �/Ai/ �����Nt. � <br /> Giy:�1��.�-0�.1 - - — State:._��-- Zip:�� � i <br /> � EmaiL•—� _ - - —Phone: (�L,S ��� -�[Xpg' ' <br /> Total Co6t lo Install Device (from contractor invace):$__ __ � <br /> � --- - - ' <br /> � I,the properry ownor,request ro hava lhe City ot Everatt Backwater Prevention Device rebate check ' <br /> for the installatlun of the device at the above referenced property address he made payable to,and � <br /> � senl to,the vendor specifind on the back o(this torm. By request(ng the rebate check be made � � <br /> payabic to ihe vendor, I agree to the following: <br /> , i <br /> 1. I vrill not mcelve a rebatc check dlrectly irom the City of Evere�t , j <br /> ' 2 Assiyning payment of the rebate to lhe vondor dces not exempt me from Back�vater <br /> � ti <br /> Prevention Device Rebate Program requlremants. � <br /> i <br /> -- - - — -- — _ _ . _- — i • <br /> , I authorize ihc release of rny rebate to the vendor Ilsted on lhe back of this form pending ' ; <br /> ' approval of the comple(ed Dackwater Prevention Device rebate packet by�he Cily of Everell � <br /> , i � <br /> � <br /> I <br /> i <br /> - -c� _ �5 zo�� � j <br /> Signature of Property Own Dale 3 <br /> � . <br /> ' - — - — -- � <br /> � <br /> � <br /> I <br /> 1 j <br /> ' <br /> . � <br /> , � ; <br /> � . . . . . . . _ . _ _ _ _ ._. . . _. _ . � � � <br /> i <br /> hllps�./Imailgoogle.com' fscslr rl-sta5c�fjs�gnv�il.mvneaTM119zpPpPU.O/rrr-m IJjVarrcPiMaV[7G_UGMNN@WPV.Cd�_97JLiIW1H9RErtgG5MP5Jh9.. 111 � <br /> t <br />