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Bac.kwater Prevention Device R�bat,� Program <br /> Vendor Payment Option Form <br /> Project Number: (G�fy�o Provide) <br /> �ieasa coii�pieiz �oti� s�des of iiie fon�n <br /> Property Owner Section: <br /> 1 .�j�� , -- i <br /> Property Owner Name: �i Yl i e-1 L-'1 'Q ��'-'��� �� � I <br /> IInstallation Address: o��U� � rl1 G '�—� ' I <br /> Clty: �VP'rC �' State: �C� Zip: ���� <br /> Mailing Address(il diNeranf): �� ��� ��� r p <br /> City: J � �G��e� Stale: 1/-�� Zip: !O .Z �S <br /> Emai� �1,1�V�r�_—r L�J_P Y' LOM Phone: �/� 3� �/ BZ2— <br /> � ��7 �•�,�`7 / <br /> Total Cost to Inslall Device (!rom confraCtor invoice): S G y -- <br /> i. the property ovmer, requesl to have the City of Eva:rett Backwater Prevenlion Devlce rebate check <br /> for lhe installation of the device at Ihe above referen�ed property address be made payabie to, and <br /> sent to, the vendor specified on the back of Ihis torm By requesting the rebate check be made <br /> payable to the vendor, I agree lo the lollowing: <br /> 1 I �vill not receive a rebate check dlrectly (rom Ihe Cily ot Everel�. <br /> 2. Assigning payment oi the rebate to lhe vendor does not exempl mc from 8ack�vater <br /> Prevenlion Device Rebale Piogram requirements <br /> I aulhonze th� release o(my rebale lo Uie vendor listed on the back of lhis (orm pending <br /> approval of the completed Backwater PreveNion Device rebate packel Ly the City ol Everell <br /> � �,�,�QC� Uk v�� .�O�'+ "��Z.D�S I <br /> J � 3 <br /> S�gna�iire of Property Owner Date � <br />