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_ i <br />, ' Backwater Prevention Device Rebate Program <br /> /�'� Vendor I�ayment Option Form <br /> Projecl Number. _ _ _.. _ (G:y fa Pnrv,ciP) <br /> Piease complete boih sides of the form <br /> Property Owner Section: <br /> Property Owner Name: __�/J�/ L�� �J • I-� � R�Q TT <br /> Inslalla6on Address: � S-�_L�y_T — I <br /> � Cily: E�J�� T? State' �1)A . Z�P��r�--- <br /> I i�lailing Address (i(diBerent): <br /> Gty. — State: _. Z'P'--- - <br /> ! Phone. ( ) _ <br /> EmaiC ------ -- <br /> ITotal Cost to Instail Device ((rom contraGor invoice): S �JSG�p_ 6� -- <br /> � — -- .— <br /> I, the properly owner, requcst to have the City of.Everett Back�vater Preventior� Device rebale check <br /> (or Ihe inslallation of lhe device al the above referenced property address be made payable to, and <br /> sent �o, lhe vendor speci(ied on lhe back o(this form. By requesting lhe rebate check be made <br /> payatle to the vendor, I agree lo the tollowing. <br /> 1. I will not receive a rebale check direclly from lhe Gry of EvereU. <br /> 2. Assigning payment of the rebale lo the vendor does not exempt me(rorn Backvr�ter <br /> Prevention Device Rebale Proyram reyuiremenls. <br /> �- - — <br /> I authorize ihe release of my rebate lo lhe vendor listed on the back of lhis(orm pending <br /> approval o(the compleled Backwater Prevention Device rebate packet by the City of Everetl <br /> I� �' .�..�- �� --- 3 ��3 - �s , . <br /> , Signature a(Property Owner Dale <br /> �_. - - -- - -- - -- — - <br />