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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />� Projecl Number. (City fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: �=vP N ��n Q� w EL L <br />Installation Address: 9Z � Co`b� qv E <br />City: F V ercr FE Slate: W A Z;p; 9�ZU l <br />Mailing Address (if diHerentJ: <br />City: Slate: Z�P�_ <br />Email: <br />e�o��we11Z']OO qm"�`. coM Phone:(2tio) 330 -�I12 � <br />88 <br />Total Cosl to Inslall Device (from contraclorinvoice): $ 2'y31. <br />I, Ihe property owner, request to have the Ciry ot Everett Backwater Prevention Device rebate check <br />for the instailation of the device at the above reterenced property address be niade payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to ll�e vendor, I agree to the following: <br />1. I will nol receive a rebate check directly from the City oi Everett. <br />2. Assigning paymenl of Ihe rebate to the vendor does not exempt me from 13ack�vater <br />Prevention Device Rebate Program requirements. <br />I authonee lhc release oE my re6ale to the vendor listed on the back o( lhis form pending <br />approval of lhe completed Bar.M��ater Prevention Device rebate packet by the Cily of [verelt <br />_ /;..._ <br />,1,� `l - i 7 - �.5 <br />Signalure of Property Owner Date <br />