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�� Backwater Prevention Device Rebate �Progra�n <br /> Vendor Payment Option Form <br /> Projert Number _ ___ _ _ ___ __. (City to Pmvidr) <br /> Please complete both sides of the form <br /> Property Owner Section: � <br /> r--- — ----- - <br /> � PropeRy O�vner Name�.�'� �'�6� -- �� <br /> Installalion Address: L�p�j----1� _ .—_ I <br /> � - <br /> Cit��� State _�C�_2ip:--�� e�4� I <br /> Mailing Address(if diBerent): <br /> City: __y State ZiP� _ I <br /> Email: �`_ Phone: (//d5� .,758'_`�d J 1 <br /> ' Total Cost to Ins�all Device (from confrac(or invoice): $�.y JS��� I <br /> I -- - — -------- — _� <br /> I, the property owner, request lo have the City of Everetl Backwaler Prevention Device rebale check <br /> fcr the installalion of lhe device af Ihe above re(erenced property address be made payable ta, ind <br /> senl lo, the vendor specified on the back of lhis fonn. By requestiny Ihe rebate check be made <br /> pnyable lo the vendor, I agree to the (ollowing: <br /> 1. I will nol receive a rebale check direclly from lhe City o(Everett. <br /> _' Assigning paymenl of the rebale to the ventior does not exempl me from Backv+ater <br /> Provenlion Device Rehate Proyram requirements. <br /> �I aulhorite lhe release of my rehale lo Ihe vendor listed on Ihe back ol lhis form pending <br /> ' approval o(the completed Bar.ktval<:r Prevention Device rebate packel by the City of Everett <br /> ���' _ 3- 7'�o,cs <br /> Signalure of roperty Owner Date <br /> I <br /> � <br />