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� Backwater Prevention Device Reb�te Program <br /> Vendor Payment Option Form <br /> Project Num6er: _ (Gty fo Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name� l,lifi C•l'1�� � �r� /i^LI <br /> Insiallation Address: ____ a/�-�J. I�u G�C�i^ fJv.� <br /> city: __ E✓!rl!� _ ---state: Lcl/� zip: 9��U / _ <br /> tvlailing Address(iI dilferen(f _ 93�-8 /�� /h4���— ��� <br /> City: ���h� �� State: _W� Zip: 9�U � � <br /> Email: G'CI�� � C�-O �� C U/'vl Phone: (��S� -3 y3 �S �7 <br /> Total Cost lo Install Device (Irom conlractor invoice): $��S T��� <br /> I, the property owner, request to have the City o(Everett Backwater Prevention Device rebale check <br /> for the installation of the device at the above referenced property address be made payable to, and <br /> sent lo, Ihe vendor specified on the bock of thi,torm. By requesting lhe rebate check be made <br /> payable to ihe vendor, I agree to the following: <br /> 1. I will nol receive a rebale check directly from the Ciry of Everelt. <br /> 2. Assigning payme�t of lhe rebate lo lhe vendor does not exempt me (rom Backwater <br /> Prevenlion Device Rebale Pwgram reyuiremenls. <br /> I aulhorrzc lhe release of my rebate to the vendor listed on the back of this form pending <br /> approval of ihe completed 8ack�vater Prevention Device rebate packet by the City of Everett <br /> 1�� � ,� �/ i� <br /> SignaWre of Property9Gvr�r Date <br />