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Backwater Prevention Device Rebate Program <br /> E Vendor Payment Optiori F�orm <br /> Project Number' _ _____ __(City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name �vn/AL� � —S��Gl-l!ES <br /> Inslallation Address: .?�/7 �G���LC�!P 9�� <br /> c�iy:�"✓F.��� � s����� _ /�_z�p: �s1�z.�� <br /> Mailiny Address (if diReren(); �?��Q 9 /.��/-��/�` S' <br /> Cily:�t /�j�✓��_ Slale: I/}�� Zip:_��j�,�� <br /> Email��„/�_�. r _���/L_S n/i'�52�% e�ry! Phone: ( )�l6 �•7=�/�/O <br /> 00 <br /> Total Cost to Install Device ((rom confracforinvoice): $ ���(��� <br /> I, the property owner, request to have lhe City of Everetl Backwater!?revenlion Device rebale check <br /> for ihe ristallation of�he device at lhe a6ove re(erenced property address be made payable to, and <br /> sent to, lhe vendor specified on lhe back o(Ihis form. By requesting the rebate check be made <br /> payablc to lhe vendor, I•agree lo the tollowing: <br /> 1. I will not receive a rebale check directty from lhe City of Everett. <br /> 2. Assigniny paymenl of tfie iebate to lhe vendor does nol exempl me from Backwater <br /> Prevention Device Rebate Proyram requirements. <br /> I authorize the release of my rebale lo lhe vendor listed on the back of lhis form pending <br /> approval of the completed 8ackwater Prevention Oevice rehale packet by the City of Everett <br /> �� � —�_ � u��- �%- �O/.5—_ <br /> Signalure of Properly Owner Date <br />