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( _ _ .-- - - __ - <br /> � Backwater Prevention ��vice Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (Cify fo Provide) <br /> Please compiete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name:����i✓ ����_`l�P <br /> Installation Address:_� 2�IL_�C:.v���. r\(�i' . <br /> I City:r�/c�CT� State: l��W _Zip: �82�7I <br /> � <br /> , Mailing Address (i(di'KerenQ: S A l� k: � <br /> City: 5tate; Zip: <br /> Email:��F�(Z.'Tr'P � �r+tC.►16r'r ,N� Phone:��Lf). �Z'�°—. ) 3 � � <br /> Total Cost lolnstall Device((rom co.ntrac!orinvolce): 5 �l�s�(��� ' <br /> I,the property owner, request to have the Cfty oi EvereQ[3ackwater Prevention Uevice rebaCo check <br /> for the installation of the device at the above re(erenced pi:�peAy address be made payable to,and <br /> sent to,the vendor specified on the back of lhis form. By requesfing the rebate check be made <br /> payahle to the vendor, I agree to the tollowing: <br /> i1. I will not receive a rebate check direclly from lhe Cily of Evereil. <br /> 2. Assigning paymenl of Ihe rebate lo lhe vendor does nol exempt me from Backwaler <br /> Prevention Device Rebate Program requiremenis, <br /> 1 authorize the re�ease ot my rebale to the vendor listed on the back of this form pending <br /> approval of the completed Backwater Prevention D.evice rebate packel by;he City of Everett <br /> ��' 2- Z3 - I.� <br /> ISignature of Property Owner Date <br /> � <br /> � -- -- --- — <br /> I <br /> I <br />