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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number (Cd}� to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O.vner Name: 1✓e1S_�L✓GLui ST <br />Inslallation Address: �/ � ion _ <br />Gty: �vti� i� State: �✓'p' Zip: i��l <br />Mailing Address (ildillerent): <br />Cily: <br />Emaii: <br />Slate: <br />Total Cost to Inslall Device (Irom contraclor invoice): 5 <br />Zip:_ <br />Phone:(Zc(.)�LL /G37 <br />Sa - � <br />I, the property o�vner, request to have the City of Everett Backwaler Prevention Device rebate check <br />tor the inslallation of the device at the above referenced propeAy address be made payable to, anA <br />sent to. the vendor specified on ihe back of lhis form. By requesting the rebate check be made <br />payable to lhe vendor, I agree to the (ollowing <br />1 I�vill not recerve a rebate check direclly (rom the City o( Everelt. <br />2. Assigning payment of lhe rebate to Ilie vendor does nol exempl me (rom Oackv�ater <br />Preventicn Dewce Rebate Prograrn requiremenls. <br />I aulhorize lhe release of my rebale lo Ihe vendor listed on the back of lhis (orm pending <br />approval of Rie compleled Backwater Prevenlion Device rebale packet by the City of Everelt <br />�/ <br />ig' alure of Property mer <br />��� <br />Date <br />