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Back�:;ater Prevention l�evice Re'.. �2e Program <br /> Y4ndor Payment Option rorm <br /> Project Number. (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Sectior: . <br /> Property Owner Name: I`�N�`�� 1 `� r � �'-nr <br /> Installation Address: �2� ��-�`{ nv� <br /> City: F•I�-2� �� State:�.�% �` _Zip: ���Z�� <br /> Mailing Address(il diBerenf): Z� ` \P, �v� N� <br /> City: ��R1!�p;Jb State: ��� !k Zip: ��3`� - � � ��0 <br /> Email: ��� ���-*.r� Llv�. Cvr^ Phone: (y2� �:J� �17 3 . <br /> Total Cost to Install Device (from contractorinvoice): $ ���� � SC� <br /> I,the property owner, request to have the City of Everett Backwater Prevention�0evice rebate check <br /> for the installation oi the device at the above referenced property address be made payable to, and <br /> sent to,the vendor specified on lhe back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will not receive a rebate check directly from the City of Everett. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my re .ele to lhe vendor listed on the back oi this form pending <br /> approval oF the completed Backwater Prevention Device rebate packet by the Cily of Everett <br /> - � Z-8- � y <br /> Signature of Property Owner Date <br />