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i <br /> i <br /> i <br /> � Bac�.water Prevention Device Rebate Program ' <br /> Vendor Payment Option Form i <br /> � <br /> Project Number: (City to Provide) i <br /> I <br /> I <br /> Please complete both sides of the form � <br /> I <br /> Property Owner Section: ' <br /> I <br /> i <br /> i <br /> Properiy Owner Name: �� �/1�G1��1 Vl <br /> Irstallalion Address: U� � Q�� vlr`e- �1-��� <br /> City ��/��i'�� v Slate:�i�Zip � �� I <br /> Mailing Address (if diI/erent): � <br /> i <br /> City State: Zip: ; <br /> Email: I�0���'�II/U�1 @ Cla'1���I,S� � n Phone: (�IZ� .�LU'nI S S 3 � <br /> Tolal Cost to Install Device((rom contractor invoice): S 7> �'1 { . % •� <br /> 1 <br /> � <br /> a <br /> 1,the property ov✓ner, request to have lhe City of Everetl Backwater Prevenlion Device rebate check i <br /> for the inslallation of the device al lhe above re(erenced properly address be made payable lo, and i <br /> sent to,the vendor specified on the back ot Ihis Torm. By requesting the rebate check be made ; <br /> payable lo the vendor, I agree to the(ollowing: i <br /> i <br /> i. I will not receive a rebate check directly(rom ihe Ciry of Everett. � <br /> 7.. Assigning payment oF the rebale to the vendor does not exempt me from Backwater ; <br /> Prevention Device Rebate Program requirements. <br /> I <br /> — —-- i <br /> � <br /> I authorize the release of my rebate to the vendor listed on the back of this form pending i <br /> approval of 1he completed Backweler Prevention Device rebate packet by the Ciry of Everett � <br /> I <br /> °I )It�lls ; <br /> ; <br /> SignaWre of Propehy Owner Da(e ; <br /> - -- - I <br /> � <br /> � <br /> i <br /> � <br />