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, <br /> � <br /> i <br /> ; <br /> i <br /> F3ackwater PrevenYiooi Device Rebafe Prograrre ' <br /> Vendor Payrrient Option Fc.�rm i <br /> I <br /> i <br /> Project IJumber (City to Provide) ! <br />� k <br /> Piease complete both sides of the Form � <br /> i <br /> s <br /> Property Owner Section: ; <br /> Property Owner Name ����1��� r'C�u�7Z7 I <br /> InslallationA�dress � ���� G�IZ�/Ji�Y^� �I��-; � <br /> i <br /> � �p i <br /> City: L����� State: `�� Zip: !D 2-� ( : <br /> Mailing Address (i(di//erenf): ` <br /> � <br /> City: Slate: Zip: • <br /> ,� (/ �7q i <br /> Email: I�I ��'t%-r/) �T� Ccf)l,t��3f /1'��Phone' (���) �1� l����5� <br /> To�al Cost lo Install Device ((rom contrecfor invoice): $ <br /> i <br /> I, Ihe properly owner, requesl lo have ihe Cily of Everelt �ackwater Prevenlion Device rebate checle <br /> for lhe inslallalion of the device al the above re(erenced property address be made payable to, and i <br /> senl lo, the vendor specified on lhe back of ihis lorm. By requesting lhe rebale check be made. � <br /> payable to Ihe vendor, I agree to the following: ' <br /> 1. I will not receive a rebate check directly from Ihe Cily of Everett. <br /> 'L Flssigning payrnenl of the rebale l01he vendor does not excrnpt me (rom Backwater <br /> Prevention Device Rebale Program requirements. <br /> — -- + <br /> I aulhorize the release of my rebate to the vendor Gsted on Ihe back of this form pending � <br /> approval of the compleled Bachwater Prevention Device rebale packet by lhe Cily of Everett <br /> , i <br /> %L�� %c��f� � [ ' ; <br /> �// /S <br /> Signature of Propeity Owner Dato ; <br /> - -- --- � <br /> i <br /> 1 <br /> � <br /> i <br />