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� Bar.kwater Pre�rention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Plumbec GL IC/J� =/03(City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Secti�n: <br /> i Property Owner Name: �r �i_�r�`h� • �����y <br /> J <br /> � Installation Address: ,�O C7 �1lJ�C�e-� �Je- <br /> � City:�\1 Y' 2. Slate:� Zip: \���� — �5�1 <br /> I Mailing Address(ildiBe2nt): <br /> City: State: _Zip: <br /> i <br /> ; Email���w r� v�e �� Qo.r��n��t��.. '(��� Phone:(}7� '15�1 — \9'?,� <br /> Total Cost to Inslall Device(from confracfor invoice): $ � Sll.�` <br /> I, fhe property owner,request lo have lhe City of Everell Backwaler Prevention Device rebate check <br /> for Ihe installalion o(the device at the above referenced property address be made payable lo, and <br /> sent to,the vendor specified on lhe back oi this form. By requesling the rebate check be made <br /> � payable to the ve�idor, I agree to the following: <br /> I <br /> � 1. I will not receive a rebate check directly from the Cily of Everett. <br /> � 2. Assigning payment of the rebate to lhe vendor does not exempt me from Back�vater <br /> Prevenlion Device Rebale Program requiremenls. <br /> � <br /> I authorize the release o(my rebate lo lhe vendor lisled on the back of this(orm pending <br /> I approval of Ihe completed Backwaler Prevention Device rebate packel by lhe Cily of EvereU <br /> � <br /> i y,. � 2.- � <br /> � <br /> SignaWre of Property Ow�er Date <br /> � <br /> I <br /> i _ <br />