Laserfiche WebLink
� Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Numbec _ _ _ (Ci�y to Provide) <br /> Please complete both sides uf the form <br /> Property Owner Section: <br /> ( ------ - --- - --- __ -- - - ------ . - — ——'I <br /> Property O�vner Name: _ D � l� �L w i S __ <br /> Installalion Adtlress: __Z1 I sS__/���k�e �_���C -___ --_ _— __ __-- I <br /> I Ciry: L�L'� E rT Sta�e: t�i` Zip `1 k 2- v 1 <br /> iMaihng Address (ildiHeren!): <br /> I Cily. — -- State: Zip. - --__ —-- <br /> Email: 'rcY{�� L �� �lk � �� C���• �L-�'�--Phone: (y2y_�5�� -fv�3S�I <br /> Tolal Cosl to Install Device(Iiom cont�actor invoiceJ' $ z S� ��• �1 � <br /> - <br /> I,the property owner, request to have lhe Cdy ol Everett Backwater Prevention Device rebate check <br /> for the mslallation of the device al the above re(erenced properly address be made payable to, and <br /> sent tq the vendor specilied on the bar.k o(this torm By �equeslmg the reba�e r.heck be made <br /> pa;ab!e to Ihe vendor, I agree to the followinq: <br /> 1 I wdl nol recerve a re�ale check direcUy Irom the Cily of Fverett <br /> ' 2 Assigning paymenl ti(the rebate to the ventlor does not exempt me Irom �ack�valer <br /> Prevention Device Rebate Program requirements. <br /> � - _ - -------- I <br /> I authorize Ihe release of my rebate lo the vendnr hsled on the back of Ihis form pending � <br /> appiov�l of ihe completed Backwater f'revenlion Device rebale packet by Ihe City of Everett ! <br /> I <br /> � <br /> � <br /> Signature of Property Owner Date I <br /> I <br />