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Gmall: debbicCapolloplumbing.com <br />� Backwater Prevention device Rebate Program <br />Vendor Payment Option Form <br />Pr�Jecl Number. _ (City lo Provide) <br />Please complete both sides of the fonn <br />Property Owner Sectlon: <br />PropertyO�vnerName: Zii 1�i'2o2v � 1n1nR���^ �'bh L•� <br />Installalion Address: <br />c�ry: Eve�e.�- —s�aie ��JA z��: R8Zo1 <br />MailingAddress(i/diBerenf): IS�OU S� 3bn' 1�Ac`e � IbU <br />City: �4H4vv�-t- _ Slate: W 1� z�p: 9gb�� <br />Email: I �-»-1. .v o. 1✓1Y��'hev��tq�•�E .co�+ Phone: (7d{,) 425-4Sq o <br />Tolal Cost to Inslall Device (Irom confracfor invoice): S Z� SOo <br />I, Ihe properiy owner, requesl lo have lhe City of Everelt Backwaler Prevention Device rebate check <br />for Ihe installation oF Ihe devico al lho above relerenced property address be made payable to, and <br />sent lo, C•e vendor specified on Ihe back of Ihis larm ay requeshng the rebale check be mado <br />payable to the vcndor, I agree to Ihe (ollowing <br />'. I will nol receive a rebate check directly iram the City oF Everetl. <br />2 Assigning payment ot Ihe rebale lo !he vendor does not exempt me from Backwaler <br />Prevention Deviw Rebate Proyram requiremenls. <br />I authodze the release o( my rebate lo the vendor listed on the Uack of Ihis form pending <br />approval ot the compleled Backwaler Prevenlion Device reb�te packel by Ihe Cily ul Everelt <br />„ n 1 � .�. <br />, ' I>>'� ti�i P�.� . ._-_.� '� l/.� ._ <br />__. r'�..�, � %����� �.�J._"" _ <br />Signaturo of Q p� erty Owner Date <br />