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� Backwater Prevention Device Rehate Program <br /> Vendor Payment Option Form <br /> Pro�ecl Numhet _ (C�ty lo ProvidPJ <br /> Please complete both sides oi the form <br /> Property Owner Section: <br /> --- — - — _ _ � <br /> Ir � � k . ���deS �� <br /> PropeAy Owner Name: � c� -<=�° <br /> I Installalion Address 2� � 5 [��n-�' �T _-- -- I <br /> I <br /> c�ry: �J e r e t+ ---sia�e: �1�- zip: `�`�� I ---___ <br /> Mailing Address(il diHerent)� _ __ _ __ _ <br /> City: _..-_- _ --- - State _ Zip: __ <br /> Email: _p� f.�erho�5��_ComCa.S-F' , r1e1" Phone: (c�z�`��9 - L��_ <br /> � Tola� Cost to Install Device (Irom confracfor invoice): $_ o�i7l•o b _____ I <br /> L _ — --- ___ _— ---- <br /> i, the property owner, requesl lo have the Ciry of Everett Rackwater Prevention Device rebale check <br /> for Ihe inslallation of Ihe device at Ihe above referenced propeiiy address be made payable to, and <br /> senl to, lhe vendor specified on Ihe back of this(onn. By requesling lhe rebale check be made <br /> payable to Ihe vendor, I ayrce to Ihe following <br /> 1. I will not recerve a rebate check direclly from the Gty of[verett. <br /> 2 Assigning payment of the rebate to Ihe vendor does not exempt me Irom Backwater <br /> Prevenlion Device Rebate Proyram reqwrements <br /> I authorire the mleasc of my rr.hate to the vendor listed on the back of ihis torm pending <br /> approval of Ihe completed Eiackwaler Preventwn Device rebate packet by ihe City ot Everelt <br /> c � ' �����`_ � • �'� - 20 i � <br /> S, ature of Property Owner Date <br />