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OCT-23-2015 05�59 From:142S�77�6c9 Naee.C'ti <br />8ackw�ter Prf�vention Device Reba:e Program <br />Q VQn�,�or Payment Op#ion Form <br />Projsc, tJumCer, � (Clt}� to Provide) <br />Please comp{ete bo'�`� sides o# the �orm <br />Property Owner Sect(Qn: <br />Properiy O�vner Nsme: � r�P.�I S� lL �JAVt�i�} OVl /�� I!}. KYi f �.�X <br />h <br />�nst�i�auon tiddress �L�113 Le�h av cl (��r- ' <br />City: � V-�'e '�"� State:l.l�E Zip: a�( �� ' <br />�viallkr� Add�'e6s (!!drfiereN); <br />i <br />Ciry: Stst�: _ Zlp: � <br />cmail:tjaX�n+vYlihkQi9Li�.��� (c� a�,,�4i 1 tGVKPhorte: (/�4D �' t%-i'to�- i <br />—�7 <br />Tol3f Cost ro Inst, Il Uevice (from confractori�wlce}; S __ _ <br />�,1he Propefry owner. lequeat to fiave thq City of Everett BacAwater Frevertt}on Devirz rebate cheok <br />for !he inatallaUon of the device at No above rei'erenced propeR; address 6e mede payablo to, end <br />sent �, lhe vendar specified or ihz ha�k of �his form. Sy mquestirc, tne rehaJe check be made <br />payabla to tbe Vendor, I agree io me foqowing: <br />1. I �till not receive a rebale chack dir�.tty from the City of E�,rerQlt. <br />2. Aseign{rIg paymsnt of the rebate to the vendor does nOt axempt me irom 8ackwater <br />Prewndon Devlo� Robaro Program requiramonis. <br />I authonze Ne release of my rebato to ihe venCor listed on Ihe back of ihis fnrfi pending <br />apprnval of the completed BaGnvoter PrevenUprt Dov!c� rebate packei by !he City of Everett <br />� <br />� <br />�G~23-h � <br />;' <br />Date ' <br />