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. .. _, _ . ; <br /> _ : . � <br /> y <br /> Backwater Prevention Device Rebate Proc�rain i <br /> Vendor Payment O�tion Form � <br /> � <br /> ; <br /> Praject Number. (Ciry to Provide) ' <br /> i <br /> _ i <br /> � <br /> � <br /> " Please c.ompletp tioth sides of the form .` � <br /> , � <br /> : � <br /> , <br /> Property Owner Section: :. ';; ' ' ` ? <br /> � <br /> � i <br /> i <br /> �.�1c1( ����I I� . ' 3 <br /> Property Owner Name: ' <br /> _ _. , . . . s <br /> , <br /> Inslallation Address: o�� I � �-Ut��c»G� j <br /> ��GZU � � <br /> City: I:LUP,YC''�� State: l,� (�-._ Zip: � <br /> t, " <br /> Mailing Address (il dillerenq: ��� �0 �11�1�6 {V1�p�1 '�Uf; � <br /> i <br /> City: 1- \l E'i r� hi S�ate: ��' Zip: ��ZG � � <br /> L ��y �071 C.� GU� . � <br /> Email: �t'� �',Qrn Phone: (4)�7r;.r:',i !-1,;, , <br /> j�. . i <br /> Total Cost toJnstall Device,(trom contractorinvoice): $ �`��'i 4� � �_ i <br /> ^ _ � <br /> I, the property owner, request to have the Ciry of Everett Backwater Prevention Device rebale check ' <br /> for lhe inslallation of the device atlhe above referenced.propefty address be made`payable lo;and � <br /> sent lo, the vendor specified on the back of this form. By requesting the rebate check be made � <br /> payatile to lhe vendor, I agree 10 the following: � <br /> i <br /> 1. I will not receive a rebate check directly from the City of Evereti. ' ( <br /> 2: Assigning payment of the rebale to the vendor does not exempt me from Backwaler � <br /> Prevenllon Device Rebate Program requiremenls. i <br /> I <br /> --.- � <br /> -- — - f <br /> 1 aulhorize Uie release,ot my rebate to the vendor listed on tha back o(fhis form pending ; <br /> approval of the completed Baokwaler Preventionbevice rebate packet by the City of Everett � <br /> f <br /> . _ i <br /> I <br /> ( � i <br /> � I , ` � <br /> (.i�'/11 C/Cl, l;�l.�,� , �_" I �l- 1,01�; f <br /> �( , <br /> S ignature ot Property Owner� Date � <br /> i <br /> — i <br /> — � <br /> I <br /> ,.. . <br /> . <br /> , _ i <br /> . . � . . , .. ����,:�, .r � ��. . ,���� :, ,���„� �" � i <br /> ` i <br /> . ... . .: . . . . . . . . . . . _ . . . . . . _. � � I <br />