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� <br /> 1 <br /> � <br /> � <br /> Backwater Prevention Device Rebate Program � <br /> �r Vendor Payment Option Form � <br /> � <br /> � <br /> Project Numbec (Crly to Frovide) � <br /> f <br /> Please complete both sides of the form ( <br /> � <br /> Property Owner Section: i <br /> r— --- � i <br /> � Property Owner Nam� �C 5 n1 �fr�ri�'fOriL� � <br /> , v ( <br /> Ins'�alia;ion Address: �`1 I �,� �,n r ,S f __ j � <br /> � � <br /> Gry: �Jc,rr.Fl� State: I,JA Zip %`���1 � <br /> I � � <br /> �dading Address (rl d�Nerent) I � <br /> City: State Zip � <br /> I <br /> Emad �� �G.}'•• , � � �'U�:,cr�F• �,i h Phcne (i�.}-) ?to-3743 � <br /> `�_ ' I <br /> � <br /> Total Cost to Ir.stall Device (/rom cor�ractorinvoiceJ S ��_�yY � <br /> L_- — <br /> I, the proper,y owner, request to have tne C�ty o;Everet, Backw2ter Pravention Device rebate check � <br /> for the installat�on of Ihe device at tf�e above referenced propery address be made payable to, and � <br /> senl to, the vendor spec�fied on the bac't of this (orm. By requestng lhe reCate check be made <br /> payable lo lhe vendor, I agree to Ihc(ollo�ving � <br /> i <br /> 1. I will not receive a rebate check direc;ty from the City o' Fveret; � <br /> 2 Assig^ing payment o!lhc reba;e to Ihe vendor aocs not exempt me (rom Backtivaler • <br /> ; <br /> Prevention Device Rebatc Program requiremen;s � <br /> --- -- ---- � <br /> � <br /> I authorize the release of my rebate to the venoor listed on the back of this form pending ; <br /> approval of the completed Fiac4water Prevention Dewce iebale packet by ihe City of Everett i <br /> � <br /> ' ��,1,�•.i, .�.,nciY�ti- 9-.�-,j� <br /> Signature of Property O�vner Date f <br /> � <br /> ._ - -------- — — - j <br /> 1 <br /> � <br /> 1 <br /> � <br /> � <br /> i <br />