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, - - — — ---__-- --- --- - - -- - - <br /> � <br /> � ' <br /> ; ; <br /> ' �Backwater Prevention Device Rebate Program ' <br /> � <br /> Vendor Payment Option Fnrm <br /> � <br /> � Project Number, (City to Provide) <br /> Please complete both sides of the form <br /> � <br /> , _ <br /> ' Property Owner Section: � <br /> � — i <br /> Property Owner Name: Matt Freed � <br /> Installation Address: 1531 Wetmore Ave � <br /> I <br /> City: Everett Slale: WA _Lp;98201 <br /> Mailing Address(lfdiherenq: � � <br /> ' � 1 <br /> , Cfty: State: Zip: I � <br /> i Emeil: mmfreedCa�outlook.com Phone:(36Uj 4642GU5 ; <br /> I <br /> i Total Cost to Install.Device(/rom contracfor invoice); $ 2,447.58 ' <br /> � <br /> I <br /> I,the property ownor,request to have t�^Clly of Everefl Beekwater Preventbn Device rebete check i <br /> for the installation of the device at the above�eleren�ed property address be mede payable fo, and <br /> sent to,the vendor epeclfled o�the beck of this krm. By requesling M�a rebete cfieck be mode <br /> payabie to the vendor, I agree to the following: <br /> 1. I wiil not receive a rebate check dlrectly from the Ciry of Everett. <br /> ', 2. Assigning payment o(Ihe re6ate to the vendor does not exempt.me irom Beckwaler � <br /> Prevention Device Rebate Program requiremenls. ! <br /> —_-_ ! <br /> � I authorize the release of my rebate to the vendor listed on the back of this form pending j <br /> approval of the compieted Backwaler Pravention Devlce rebate packet by the City of Evorett � <br /> i <br /> I <br /> I� !/`'?�j�/� � -��c /� <br /> , , <br /> I Signature oi Property Owner Date , I <br /> � <br /> � <br /> i � <br /> � <br /> � j <br /> � <br /> I <br /> , � <br />