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-- - - - - . <br /> - -- - , _ _ _ <br /> Backwater Prevention Device Rebate Program. I��p� <br /> i Vendor Payment Option Form D ��i���.. lJ V D <br /> � � A U 6 2 7 Z 0 1 5 <br /> I� P ro j e c t N u mbec (City fo P.rovide) <br /> � PUBLIC �'�ORKS <br /> { <br /> � Please complete both sides of the form <br /> Property Owner Section: <br /> � <br /> � <br /> � PropertyOwnerName:�LIFFOR-0 J�F_F2�.Y�-�[1TZOY <br /> i 1 <br /> � InstallationAddress: I�o�2 L1�ETtMORf: AV�= <br /> � -- — <br /> City: �ERE7T Slate: WRS41 Zip: 9�2�1 <br /> Mailing Address(iI dilferent): ��32 W ETI�'10� ��t <br /> I City: �VC-7L�TT _ State��5.�_Zip:�I��A� <br /> 1 Emaii: Phone: (�f1.�_z.�_(���n� <br /> I Total Cosl to Install Device (Irom confractorinvoice):$��_S� <br /> � I, the property owner, request to havF:the City of Everett Backwaler Prevention Device rebate check <br /> (or lhe inslallation oF the device at the above referenced property address be made payable to, and <br /> I� senl lo, Ihe vendor speci(ied on Uie back of this form. By reyuesting the rebate check be made <br /> � payahle to the vendor, I agree to Ihe following: I <br /> 1. I will not receive a rebale check direclly from the Cily of Everell. <br /> 2. Assigning payment of Ihe rebate to lhe vendor does not exempt me (rom Back�vater <br /> Prevention Device Rebate Program requiremenls. <br /> I authorize Ihe release of my rebale to the vendur listed on Ihe back of this form pending <br /> eNNiov�! of the compleled Backwater Prevenlion Device rebatc packet by the City of Everell <br /> � l!,/� T771.t.(�.�1 FJ ZD /!� <br /> v 7'��"" <br /> SignaWre oi Propert wner alc <br />