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i <br /> � <br /> � <br /> i <br /> Backwater Prevention Device Rebate Program , <br /> Vendor Payment Optior7 Form <br /> ; <br /> i <br /> Project Number:_____. (City fo Provide) <br /> i <br /> Please complete both sides of the form � <br /> Property Owner Section: ' <br /> --- -- � <br /> �` (� a �/I �Jc i rdf� �cr,��ci2 f <br /> Property Owner Name: __,r �/�CI G!� N __ , <br /> V / / <br /> Inslallalion Address:��� C�y71�? ('��� � <br /> Cily: �il/�iYU�� _ State: lilil� Zip: 7 �2 � � — <br /> ; <br /> � <br /> ; <br /> Mailing Address(if diHerent): — � <br /> i <br /> City: State: Zip: � <br /> Email: Phone: ( )_--- � <br /> Totai Cost to Inslall Device(lrom cailractor invoice): 5 �� J I • ��� <br /> I,the property ovaner, requesl to have the Cily oi Everett Backwalcr Prevention Device reha�e check � <br /> for the installation of the device at lhe above referenced p�operty address be rriade payabie to, and ! <br /> sent to, the vendor specifir.d on the back of Ihis form. By requesling fhe rebate cher.k be made <br /> payable lo Bie venAor, I agree�o ihe following: � <br /> 1. I will not receive a rebate check direcUy (rorn Ihe City oi Everett. � <br /> 2. Assigning paymenl o(Ihe rcbate lo Ihe vendor does not exempt me from Dackwater : <br /> Prevention Device Rebale Program requirements. <br /> — - - ----- — � <br /> I authorite the release of my rebale to thc vendor lisled on lhe back of�his form pending ; <br /> approval o(U�e crompleted E3s�ckv�aler Prevertion Device rebate packet by the Ciry of Everett � <br /> � <br /> , I <br /> �,�'� �n. /� li�'��j�i_ /�L- — —��L�-� ; <br /> i <br /> 'iynalure of Property Owner Date <br /> i <br /> � � - --- - - -- ' - -- --- - ... -- -- ----- - � <br /> ._. . - -- -- - - � <br /> i <br /> . i <br /> � <br />