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; <br /> i <br /> Backwater Prevention Device Rebate Program ; <br /> Vendor Payment Optlon Furnro ; <br /> Project Number. (City to Piovide) � <br /> � <br /> i <br /> I <br /> Please complete both sides of the form ; <br /> t <br /> t <br /> � <br /> Property Owner Section: ; <br /> � <br /> Property Owner Name: ��"�� L • �D� � <br /> 1 <br /> fnslallationAddress: 3�� � �z'�-�- � <br /> � , <br /> City: LGC4�rL'�Z` Slate: Gc,l�9- ZP:. Gj'�'2-v / ; <br /> i <br /> Malling Address(if ditferentJ: <br /> 1 <br /> City: State: Zip: <br /> EmaiL• �GGLlIOlf.:1��� �111-1-0b.Cc'm-�. Phone:('t�� ��- 7'z�s � <br /> Total Cost to lnstall Device(from contracl�rinwice):$ 3�3 3 0, � � i <br /> i <br /> 1, the property owner,tequest to have the City of Everett Backwater Prevantion Devi�e rebale check � <br /> fur the installatlon of the device at the above referenced property address be made peyabla to,end <br /> senl to,the vendor specified on fhe back of Mis fortn.8y requesdng the rebate chedc 6e made ' <br /> payable to the vendor,I ogree tn the following: i <br /> 1. I will not receive e rebale chedc directly irom lhe City of Everett. � <br /> 2. Asslgning payment of Ihe rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requiremenLs, j <br /> � <br /> I <br /> I authorize the release of r..y rehate to the vendor listed on ihe badc oF this form pending ( <br /> approval of the compleied BaGcwater Prevention Devioe rebate packat by the Cityr ot Everett � <br /> I <br /> � � �-) S-a�-r ' <br /> �Qn nQ _� � I <br /> � <br /> Signature of Property er Date � <br /> i <br /> I <br /> � <br /> � <br /> � <br /> i <br /> � <br /> ; ' <br />