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t <br /> i <br /> { <br /> �ackwa4er Prevention Device Rebate Pro�rarn <br /> Vendor Payment Option Form ' <br /> ��so�,-ozp � <br /> Project Number (City fo Provide) j <br /> I <br /> � <br /> Please complete bo4h sides of the form + <br /> I <br /> Property Gwner Section: � <br /> i <br /> ; <br /> i <br /> Properly Owner Name: �r'i � L � l� Iw f C�l�u a c �j � <br /> InstallationAddress: � a4� 1ti'i A P�� 5"i <br /> '" � �, i <br /> City: E�v t /t r .— T State: ��_Zip Qi 8 �3U ] ' <br /> � <br /> Mailing Address(i/diBerentJ: � O .� v X Jr,� � 1 � <br /> I ! <br /> ciry �.i z ,2 � T ' _ State: /,J /a _Zip: 9 8 �o G <br /> EmeiL L rN.e�luG ��+ �/ A h� n .+ • C n� Phone: (Nz)5 1 3�3 -0`77�1 ! <br /> � <br /> Tota1 Cost lo Install Device (/rom contraclorim�oice): 5�75�—� ' <br /> _ j <br /> I, lhe property owner, requesl to have lhe C;.ry ol Everett Backwater Prevention Device rebate check ; <br /> for the installation ot the device al the above re(erenced property address be made payabla to, and `, <br /> senl to, the vendor specified on the back oi Ihis(orm. By requesting the rebale check be made ; <br /> payable to Ihe vendor, I agree[�Ihe follo.ving: � <br /> t <br /> 1 I will not receive a rebate check direcUy from the City of EvereB. <br /> 2 Asslgning payment of the rebale to the vendor does not exempt me from �ackwaler � <br /> Prevention Device Rebate Program requirements. <br /> � <br /> -- ' <br /> I authorize!he release of my rebale to the vendor listed on the back o(this form pending ; <br /> approval of the completed Backwaler Prevention Device rebate packel by Ihe City o(Everett ! <br /> �- "Tac. (G'/li l.c 6))f7G C (�NfG�I� j <br /> .J:i ��<c �C , � n .,� y . ; <br /> ��N[5"T G`. L i <br /> y/G.�.�..�+ n. 7f �1M .� //h.nl _ l� l •.�'�' ���1 �T I <br /> l ,. " "__ " _ I <br /> Signature o(Proparty Owner Dale <br /> i <br /> � <br /> � <br /> � <br /> I <br /> I <br /> i <br /> . • ; <br /> � <br /> . . ; <br />