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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Number: <br />r r, fy (o Provide) <br />Plee�se complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: �g'�'l�Lk • �JOJCNV7 /'el ��.St)✓I ��t�N/�v ,/H.sl <br />Installatinn Address: �bD L�4 �iler �ve . <br />ciiy: Ev�P�.tt s�a�e: W� z�P: 98'2a/ _ <br />MailingAddress(i(di/ferenq: .2(036 .SVI� �67'� �'. <br />City: Se�'��e State: 1/i/� Zip: Cig�6 � <br />Emaii: w�YS 6 DP't2Y�oiwtall •cow� Phone: (ldf� �133 'll 3_ <br />f-= <br />Totai Cost to Inslall Device (1rom conf�actor invoice): S_%`� ��� •�� <br />I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of lhe device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. Fiy requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. I will not receive a reba[e check direclly from the City of Everetl. <br />2. Assigning payment of the rebale to the vendor does not exempt me irom Bar.kwater <br />Prevention Device Rebale Program requiremenls. <br />I authorize the release of my <br />approval of the com ed B� <br />Signature of Property Owner <br />to the �n or Iisled on the back ot this form pending <br />�r Prev on Device rebate packet by the City of Everett <br />Date <br />