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1 <br /> � Rackwater Prevention De��ice Rebate Pro�3ram <br /> Vendor Payment Option Form <br /> Project Num�er.__ ____ (City fo Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> perty Gvmer Name �Q `�{/V I �i(,{1.4'1 P. �.1(,�i <br /> Installaticn Address ���� " ��fOV1'�_�4/ <br /> fo ��O �I^ � - f <br /> L'ity: C/Uf/Y L'f 1� Sizle� W k�- z��� �182U I <br /> i ,..�n/ /y,� � �� <br /> Maiiing Address (if tli7ferentJ ��Q_��P(�C.c7 f'I V'L !'�I/�_ <br /> Cily ���� Stale �— Zip � ��ZZ� ���� <br /> i Email: �/I� ��{�-Pi� v V. �� Phone: 1�'� �l✓"I ' �l D b v <br /> ITotal Cost lo Inslall �evice(lrom corfraclor invoiceJ. 5 <br /> I, the property owner, requesl lo have the Gty of Evereil Backtvater Prevenfion Dr.vice rebale �heck <br /> (or the instalWhon of lhe device at lhe ahove referenced property address be made pa�able to, and <br /> sent to, Ihe vendor specified on fhe back of lhis form. 8y requesling �he re6ale check be made <br /> payable to Ihe vendor, I agre.e to the foilowing <br /> 1. I�vill not ieceive a rebale chec.k directly Irmn lhe Cily o(Everetl. <br /> 2. Assigning paymenl of the relale lo Ihe venAor does nol exempl me Irom f3ar,kwater <br /> 4'revenfion DEvice Rebale Program requur.menls. <br /> iI auUiorize thc relcase o(my rebatF 'n the vendor I�sted on the back of Ihis (orm pending � <br /> Iapproval of the completed Backwater Prevenlion Device rebate packel by the Ciry o(Everell <br /> � <br /> I �� �� _ _lU - �� - ? � l�'. <br /> � <br /> iSgnature of Property Owner Date <br /> � <br />