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Backwater Prevention Dev�ce Rebat:e Program <br /> Vendor Payment Option Fo�m <br /> Project Number: _ _ (City to Provide) <br /> � Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Namo:.�a�1 �'S '� � P `-'1 t �__�� J 1 d� e{-_�_ <br /> Installalion Address: �� V ` v� I� �'�c ` IS Y �U �- <br /> City:� �� Y 8� State: U,)�t Z�P: q � av � <br /> Mailing Address (ildif(erent): SG d'�'L—� <br /> City: State: __Zip: <br /> 4 <br /> Email: ��� � e Y ���I S 6 � -+�na ��. Phone: ( a j 7�,3-03 � � <br /> c�� Qg <br /> Total Cost to Install Device (from confractor invoice): S_��� • p _ <br /> I, the property ow�er, request �o have Ihe City of Everett Bar.kwaler Prevention Device reba�e check <br /> for the installation o!the device at the above referenced property address be made payable to, and <br /> seM to,the vendor specified on ihe back of this form. By requesting the rebate check be made <br /> payable to lhe vendor, I agree lo the tollowing: <br /> 1. I will not receive a rebale check directly(rom the City of Everetl. <br /> 2. Assigning paymenl of lhe rebale lo lhe vendor does not exempl me from Backvrater <br /> Prevenlion Device Rehate Program requiremenis. <br /> I authorize the release of rny re�ale lo lhe vendor listed on lhe back o(this fonn pendiny <br /> approval oi the compleled Backwaler Prevenlion Device rebate packel by the City o(Everelt <br /> ����1�.� ____ ����� � �--- <br /> Siynalure of Property Owner Dale <br />