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i <br /> , <br /> ► <br /> Backwater Prevention Device Rebate Prograrri <br /> Verndor Payment Option For: � ' <br /> � <br /> � <br /> , � <br /> Project Numbe, ___ ___ (City fo Provide) � <br /> i <br /> Please complete both sides of the form <br /> i <br /> � <br /> Property Owner Section: � <br /> ----- , � <br /> Property Owner Name: �Gt U I G{ `� I�lti��tQ�-I il.Q v��'�-Kdl ! <br /> InstallationAddress: 0`3a ,___ B�Lv _ (1 �9 ; <br /> c�iy: GU(�t��l� State: W� z��: �1��?� I ' <br /> IAailing Address(ildi(ferentJ: �_�1__'��___ i <br /> Cily: State' _Zip: � <br /> Emaii: I�ASI'�nC✓I M� ��_�����11 d��—��ne: (yd,S�- �KU •�3�}� � <br /> i <br /> Total Cost lo Install Devir.e (!rom r,ontraclorinvoice): 5_ a-�{ ,�' �� � <br /> -- — - - ---- ------- � <br /> i <br /> I, lhe propeily owner, request to have the Clty of Evereri Rackwater Prevrntion Oevice rehate check '� <br /> for the inslailatinn of the devir,e al the above referenced property address l�e made payablc fo, and � <br /> sent to, U�e vendor;pecified on lhe Uack o(this form. 8y requesting lhe rebale check be made ! <br /> payablc lo ihe vendor, I agree to Ihe following: � <br /> 1. I will nol receive a rebale cher,k directly from ihe Ciry o(Everelt. <br /> 'l_ Nssignin� payment o(the rebalo to Ihe vendor dor.s not exernp� me from Back�•�aler � <br /> Prevention D�vicc Rebate Pmgram requirements. j <br /> --- - ----- - - - - - - - ---- � <br /> I authorizc thc release o(my rebal�a ro lhe vendor hsled on the back of this form pendin� <br /> appiaval o(�hr. campleted f3ar.kwaler Prevenlion Device rebale packet by lhe Cily ai Everell <br /> � ; <br /> —��1�/1�12�-- ' �-� �L 7 � . �S ,; <br /> - � <br /> Signalure of Property Owne ' Datc , <br /> i <br />