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� <br />Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. (City to Provide) <br />Please complete both sides of tha tt�rm <br />Property Owner Section: <br />Property Owner Name: Scott Larson <br />Installatlon Address: 811 Col6v Ave <br />Ciryt Everett Sfete: WA Zip� 98201 <br />Mailing Address (if diHerenf): <br />Ciry: State: Zip: <br />Email: <br />Total Cosl to Install Device (from contractor invorceJ: $ <br />Phone: (4Z5) 315-5821 <br />I, tlte property owner, request to have ihe Ciy of Everetl Backwater Prevention Device rebate check <br />for lhe installatlon of the device at the above referenced propedy address be made payable to, and <br />sent to, the vendor spedfied on ihe back of Ihts form. By requesting tt�e rebale check 6e made <br />payable to the vendor, I apree to the (ollowing: <br />1. I will not reeeive a rebate check directly from the Ciry ot Everetl. <br />2. Assigning payment o1 the rebate to the vendor does not exempt me from Eackwater <br />Prevention Device Rbbalo Proc�rem requlrements. <br />I ault�orize the release of my rebate to ihe vendor listed on the back of this form pe�ding <br />approvnl of the completed BeGcwator PrevenYan Device rebate packel by the City oi EvereH <br />�- �,/� ,/N�l�' � - I .� <br />h W <br />Signature of Property Owner <br />Dale <br />