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i <br /> Backvi;ater Preven4ion Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (Cih�fo PmvideJ <br /> Please complete both sides of the form <br /> Property Owner Section: • <br /> Property Owner Name: ��E� �� <br /> Installation Address:��_ Gr9 1 i�✓�� <br /> City: �✓e{?"i� State: Lf/f}' Zip:__��o�% � <br /> Mailing Address(if diNeren�): <br /> Cily: State: Zip: <br /> �mail: ^ �u�..r �jor,y�'Uc7� aw,u.��. Go� Phor,e: (�) �-6 0�7 <br /> �—„ - <br /> Total Cost to inslall Device (from contractor invoice): 3 oZ `t��,,�� <br /> I, lhe property owner, request to have ihe City oi Everelt Backwater Prevention Device rebate check <br /> for the inslallation of�ihe device at the above re(erenced property address be made payable to, and <br /> sent lo, lhe vendor specified on the back of this form. By requesling the rebate check bemado <br /> payable lo the vendor, I agree lo lhe following� <br /> 1. I will nol receive a rebate check direcUy from lhe City of Everell. <br /> 2. Assigning paymenl of ihe rebate to lhe vendor does not exempl me from 8ackwater <br /> Prcvention Device Rebale Program reauirements. <br /> I auUionie tfie release of my rebale to Ihe vendor listed�on lhe back of Ihis forin pendmg <br /> approval of ihe compleled Back�vater Prevention Device rebale packet by ihe City o(Everett <br /> -- 3�6�-!3` <br /> Si nature of Property O�vncr Date <br />