Laserfiche WebLink
I <br /> i <br /> kOj__ Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> i <br /> Please complete both sides of the form 1 <br /> Property Owner Section: <br /> i <br /> Property Owner Name: / '/Lie/vcp ifZez 1/�y <br /> Installation Address: .24'' CD 4 (4(--(2-17,,,71-' i <br /> /� pf9/;37-0 <br /> i <br /> City: Z7' ,� / <br /> State:� � . Zip: `�L () 1 ; <br /> Mailing Address(if different): C, _ <br /> City: /. vci/ State: L(}) Zip: 182 vI 4 <br /> ( i--) 1 1 <br /> Email: Phone 1z 'ZS�—��� <br /> Total Cost to Install Device(from contractor invoice): $ iRit q...„... <br /> I,the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at the above referenced property address be made payable to, and <br /> sent to, the vendor specified on the back of this form. By requesting the rebate check be madeii <br /> payable to the vendor, I agree to the following: <br /> i <br /> 1. I will not receive a rebate check directly from the City of Everett. t <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater i <br /> 1. <br /> Prevention Device Rebate Program requirements. <br /> I <br /> T <br /> I authorize the release of my rebate to the vendor listed on the back of this form pending <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett. at <br /> i <br /> I / / / -- <br /> iz r� 7 3 S <br /> • Si•nature of Property Owner D.to <br /> • i <br /> r; <br /> } <br /> I <br /> a <br /> • <br /> 1 <br />