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�Backwater Prevantion De�fice Rebate Program <br /> Vendor Payment Optiun f'orm <br /> Project Number. (City to Provkle) <br /> Please complete both sides of the torm <br /> Property Owner Section: <br /> PropeRy O�vner Name /[O�i,:T�D ./5'CHl��IJ�'� /fi?E�h°GN '/X�I + <br /> Installalion Atldress: / �'S //�� ��� ! <br /> � <br /> City: ��C,�]j Slate: L-✓p Zlp %���/r � <br /> I <br /> Mailing Address (i�dilferent): � � <br /> Cily: State. Zip. i <br /> Email: �P�6t IIG�(�" �/�I1•�I� •LL�/� _Phone: f�!�'� �� —/���.1� I I <br /> Total Cost to Install Device (/rom contractorinvoice)� � ��,SGv <br /> I, lhe propeiiy otimer, requesl to have the Gty o(Everett Bar,kwater Prevention Device rebate checfc <br /> for Ihe inslallation ci the device al the above referenced �uopeAy address be made payable to. antl <br /> sen!to, the vendor specified on the back ot Ihis fortn. By rac�ueslmg the rebale check be made <br /> payable�o �he vendor, I agree lo Ihe following: <br /> i. I will not receive a rebate check direclly(rom the City of Everett. 1 <br /> 2. Assigning payment of ihe rebate lo Ihe vendor does not exempt me from �ackwater I <br /> Pi^venlion Device Rebate Program requirements. <br /> i---- I <br /> II aulhorizc thc release ol my reAate to lhe vendor hstetl on Ihe back of thls form pencling 1 <br /> approval o(the compieled Beckwa(er Prevention Device rebat? packel by the Ciry of[veret� I <br /> �i <br /> ��///Ji" / _--_ I Jy IJ�. <br /> Signalure of Properly Owner ���e <br />