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i <br /> i <br /> i <br /> Backwater Prevention Device Rebate Program � <br /> a Vendor Payment Option Form ; <br /> Pro ect Number � <br /> J (City fo Provide) <br /> Please complete both sides of tfie form ' <br /> I <br /> Property Owner Section: � <br /> i — - _ i <br /> Prcpe„y Owner Name: R�esh 5urana , <br /> iInstallation Address 2326 Pine St ; <br /> I C�ty Everett State: Wa Z�p 98201 ; <br /> hlading Address(if dUle�en�) 4607 1441h PI SE , <br /> City. Snohomish State: WA Zip. 98296 <br /> Email: rajesh.surana@gmaii.com Phone (Z06�915-5709 ' <br /> i <br /> Tolal Ccst to Inslail Device(hom contractor invoicQ) : <br /> 1 <br /> I, the proper,y owner, request to have Ihe City of Everett Backwater Preventon Dewce rebate check <br /> lor the installation of lhe device at the above referenced property address be made payable to, and <br /> senl lo, the vendor specified on the back of this form. By requesting the rebale check be made <br /> payable lo the vendor, I agree to Ihe loilowing <br /> 1. I will not receive a rebate check d�recliy from Ihe City of Everett <br /> Z Assigning paymenl of lhe rebate lo the ver�dor dces nol exempt me (rem Backwater <br /> Prevention Device Rebatc Proyram requuemenls � <br /> II aulhonzc Ihe release of my rebale to Ihe vendor listed on lhe back of this form nending , <br /> approval ot the compleled Backwater Prevention Device rebate packet by the City of EvereU � <br /> I i i <br /> I � <br /> � �l ,�1 C-wL�( 08/77/2015 � <br /> I ' <br /> Signature of Property Owner Date � <br /> � ---- -- -- � I <br /> — – ------- --- � 1 <br /> i <br /> 1 <br />