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. � <br /> Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form ' <br /> Project Numt�er: (City to Pravide) i <br /> I <br /> Piease complete both sides of the form � <br /> I <br /> Property Owner Se�tion: i <br /> Prop2rty Owner Name:`�. �14 p7�1 �P� �r�� � — i <br /> � <br /> Installatlon Address:� �r`�� �\I �� �• <br /> Ciry: ��)P �1'� _ State: �� Zip: �,Ot�.� � � <br /> i <br /> Mailing Address(ifdr(lerent): � ��.s "'- �I� � �� �_ , <br /> c��y: C't-[�R_�i T _ s�a�e: ���i9 z�p: 5.�':�03 <br /> Email: Phone:� s at� ' �� <br /> Total Cost to Install Device(lrom contractorinvoice):S_���Lp�� <br /> i <br /> I,the property ovmer,request to have ihe Cuy of Everelt �ackwater Prevention Device rebate check ; <br /> ior the installalion o(the device at lhe above referenced property address be niade payabie to, and <br /> sent lo,the vendor cpecifed on the back oi this form. By requesting the rebale check be made <br /> payable lo Ihe vendo�, I agree lo the follo�viny: <br /> 1. I �vill net receive a rebala check direcUy from the Ci,y of Everett. <br /> 2. �ssic�ning paymenl of Ihe rebate to the vendor does not exempt me from Backwater � <br /> Prevention Device Rebato Program requiremenls. j <br /> I authorize ll�e relcasc o(my rebatc lo the vendor lisled on the back of this form pendinc� 1 <br /> appro�ai of ihe compieted Backwater Pre��ention Device rebate packel by the Cily of Everett <br /> i <br /> i <br /> � <br /> �"" ; <br /> ��-� �c —c,-/S' <br /> Sig� of Property O�vner Date <br />