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� <br /> � <br /> � 8ackwater F revention Device Rebate Program <br /> rr Vendor Payment Option Form <br /> Pro;ect Number ��/G//� –���__ (Cdy to Yro�:�rdeJ <br /> Please comFlete both sides of the form <br /> Property Owner Section: <br /> Properly O:�ner Name �����-���J�/�� <br /> Installalion Address: ���Z _�� /"7l'� <br /> City: ���� State: _��_Zip: �U�d� <br /> �vlailing Address (i(ddlerent): ___ _ _ — <br /> City: _— ----- – ---- State: Zip: , <br /> Email _�f.e-(�l..SY7/�2-L�TL�' '✓� 4' ��L Phone. (3���J� 17 t� <br /> ��U OD <br /> Total Cost to Install Device (Irom contractorinvoice): S ��5�v � <br /> ' ---- I <br /> ' --- -- --- ---- <br /> I, the property owner, request to have Ihe C�ly of Fverelt Backwaler Prevention Device rebate check <br /> for ihe installalion o(the device at the above referenced property address t�e made payable lo, and <br /> sent tu the vendor speci(ied on the back of this forrn. By requesling ihe rebate check be made <br /> paqahle to lhe vendor, I agree to lhe follo�ving: <br /> t I r:ill not receive a rebate check direc:ly from the City of Everetl. <br /> 2 Ass�qning paymen� of lhe rebate to the vendor does not exempt me from Backwater <br /> P�acention Device Ret�ate Program requiremenls <br /> I, I suthnri:c the release of my rebate to lhe vendor listed on lhe back of Qiis form perJing <br /> approval o( lhe completed C3ackw�ler Preventiun Device rebale packet by Ihe City oi Evere�t <br /> I <br /> r (�y_ <br /> — d f� /`.^"��1,u�--�� _ � � �--- ��. <br /> Signature of Property Owner ���P � <br /> _—J <br />