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i <br /> 1 <br /> � Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> � Project Number. (City to Prcvide) <br /> � Please complete both sides of the form <br /> � Property Owner Section: <br /> � Property Owner Name: �o��'�o-�r'u. � �+k�r�5 <br /> IInstallationAddress: \`�ZZ �,�C� �(f'___________ <br /> City:_ E-JLC��' State: W�_Zip: q�Z�` <br /> I Mailing Address(il diNerent). <br /> iCity: Slate: Zip: <br /> � Email: Phone: (3t�) 30'J-�I$�v2 <br /> Total Cost tc Install Device (�rom contractorinvolce): 5 2� `�rU <br /> I <br /> 1, lhe property owner, request to have fhe Ciry o(Everetl Backwater Prevention Device rebate check <br /> for the installation of the device at the above referenced property address 6e made payable to,and <br /> sent to,the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will not receive a rebale check direcUy from thc City of Everetl. <br /> 2. Assigning payment of the rebatc lo the vendor does not exempl me from Backwaler <br /> Prevention Devicc Rebate Program requiraments. <br /> I authorizc lhe release of my rebale lo lhe vendor listed on the back o(this form pei�ding <br /> approval of lhe compla�ed Back�vater Prevention Device rebate packel by the City of Everett <br /> i <br /> ! ��a��.�,� 12��,o�ia <br /> SignaWre of Property Owner Uale <br /> � — — ---- -- — —-- <br /> � <br /> il <br /> I <br /> � -- _ - � <br />