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Backwater Prevention Device Rebat� Program <br /> Er, Vendor Payment Option Form <br /> Project Number: _(Ciry to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Pro eK Ovmer Name: � EDVTHE PAVISH i <br /> P Y 1322GRANDAVENUE <br /> IEVERETT,WASHINGTON 9�201 ��-- <br /> Installation Address: <br /> City' State: Zip: _ <br /> A4ailing Address (ildifferent): <br /> City: State: Zip: <br /> Email: Phone: ( ) <br /> Tolal Cost to Install Device(irom contracror invoice): 5 <br /> I,the property owner, request to have the City of Everett Backv�ater Prevention Device rebate check <br /> for the installation•of the device at Ihe above referenced property address be made payable to, and <br /> sent to, the vendor specified on the back of Ihis form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will nol receive a rebate check directly(rom the Cily oi Everett. <br /> 2. Assigning payment o(the rebate lo the vendor does nol exempt me from Backwater <br /> Prevention Devicc Rebate Program requirements. <br /> I aulhorize the release of my rebate to the vendor listed on the back of this (orm pending I <br /> approval of�he completed Backwaler Prevenlion Device rebate packet by Ihe City of Everelt <br /> / <br /> . <br /> , <br /> / ,� � �i,oT �" 7�� � �`� <br /> , � . <br /> SignaWre of Property Ovmer Date <br />