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�^%�� [3ackw�eter Prevention Device Rebate Program <br /> �l�ndor Payment Option Form <br /> Pro�ecl Number _ (City[o Pro�ide) <br /> Please complete both sides of the form <br /> Property Owner Sectioni • ; � <br /> , -- --- - - -- - -- <br /> IProperty O�:ner Name: a�' '� � `�- �JQ r�41^``� S, ��� -�� �� . <br /> � Installalion Address: /3 CJ l h � <br /> I Clty: �. V e. Y�e _ State: W t� �ip:.������� <br /> hlailing Address(iI diNerenf): <br /> � <br /> Ciry: State: Zip: I <br /> Email. � "l�r o �� ��[.��L h' ra� Phone:�� �5a-�c�i�' � <br /> 1 � , <br /> --�� �'-`-�-„r�--,r, i <br /> � <br /> Tol�i�ost to Install Device (lrom confractor mvoiceJ 5 _ I <br /> L �, <br /> I <br /> 1, the property owner, roquest to have lhe City of Everett 8ackwater Prevention Device rehale check � <br /> for the installaLon of the device at the above referenced property address be made payable lo, and <br /> sent lo, the vendor speci(ied on ihe back of this form. By requesting the rebate check be made 'I <br /> payable to Ihe vendor, I agree to the following: I <br /> 1. I �a�ill nof receive a rebale check direcUy from lhe City of Everett. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwatrr I <br /> Prevention Device Rebale Program requirements. <br /> � <br /> I aidhorizc lhe release ai my rebate to the vendor lisled on the back al lhis form pendmg <br /> approval of the compleled Backwaler Prevenlion Device rebate packel by the City of Evereu ' <br /> ,S/L��;L�_��, << - %--2)— l�' <br /> i rt-� -�*� <br /> Sig,xalure of Property Owner _ �� Date <br /> �Ci��t���'�O� .�� ��l}'�p'Vi _ _ - , <br /> ` ' <br /> G <br /> I <br />