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� <br /> i <br /> . � <br /> � <br /> Backwater Prevention Device Rebate Program i <br /> l�endor Payment Option Form � <br /> Praject Number. (Cify to Provide) <br /> i <br /> } <br /> f <br /> Piease coi�iaieie boiii sicles oi iiie S`orm � <br /> Property Owner Section: i <br /> ' <br /> Property O�Nner Name: Gary G. DeMello-Wells i <br /> Installation Address: 1830 Oakes Avenue <br /> � <br /> City: Everett State: WA Zip: 98201 <br /> �'vtafling Address (il dillerenQ� same ; <br /> Ci�y: same State: same Z�P same ; <br /> Email� �arygw@hotmail.com Phone: ( 42�5 25&4330 <br /> Total Cost to Install Oevice (from contracror invoice/: S 2.499.59 <br /> ; <br /> I, the property owner, requesl to have ihe Cily of Everett Backwaler Prevention Device rebate check i <br /> �or !he inslallation of the device at the above referenced property address be made payable lo, and � <br /> sent to, the vendor specified on the hack of lhis form. By requesting the rebate check be made � <br /> payable to Ihe vendor, I agree to the following: ; <br /> 1. I �vill not receive a rebate check directly from the City of Everett. � <br /> � <br /> 2. Assigning paymenl of the rehate to lhe vendor does not exempt me from [3ackwaler <br /> Prevernion Device Reba�e Program requiremenls <br /> - — <br /> I autho�ize Ihe re ease of my rebale lo the vendor listeo on lhe back of this torm pending � <br /> approval of t cor ipleled Backwater Prevention Device rebale packet by Ihe Cily of Everett <br /> i <br /> 13-March-2015 '• <br /> i <br /> i <br /> Sic�nature of Property Owner GaryG.De6lcllo-N�ells Date ! <br /> i <br /> 1 <br /> � <br /> � <br /> i <br />