Laserfiche WebLink
t <br /> � <br /> ` <br /> � <br /> Backvrater Prevention Device Rebate Program � <br /> �, Vendor Payrn�:nt Option Form i <br /> i <br /> Pro�ect Number:_ __ (City fo Fmvide) � <br /> i <br /> I <br /> l <br /> Please complete both si�ies of the form ; <br /> Property Owner Section: � <br /> _ _ _ -- <br /> ___._ —_- -- - ------ � <br /> �� �, I i <br /> Property Owner Namc ��A•-� I�l���l-���'�DT , <br /> Z�J � � C�DAC 51��T � <br /> Installation Address n _._._—.—_----- -- � <br /> I <br /> � Ciry. �JE� _Stale: (n�{� Zlp. 1 `3 2�� - — i <br /> I <br /> Madmg Address (Hddierent): _ _ _ --- � <br /> City: _� — - - —/ Stale _. __ Lp- -- --- - _ � <br /> I Emaie ��P?v_���I� . ns5l�e�MFil� • Go►vl _Pnone: (��r� 3'�!y 7 8$� � <br /> ` I <br /> �, Tolal Cosl to Install Device (�rom contractor invoicc): $_�����-— — ; <br /> L. — -------- _ - - � <br /> - -- --------- -- <br /> , <br /> I, the property owner, request lo have the Cily of Everett Backwater Prevention Device rebate check � <br /> for Ihe installation of the device at Ihe above referenced property address be made payable to, and � <br /> sent lo, the vendor specified on the back of Ihis lorm. By requesting the rebate check be made � <br /> payable lo the vendor, I agree to the followin� I <br /> i <br /> 1. I will not receive a rebate check dfrecUy from lhe Cily of Everetl ; <br /> 2 Assigning payment oi the rebate to Qie vendor does not exempt me from f3ackwater I <br /> Prevenlion Device Rebate Program requuements � <br /> _ _ ._ j <br /> �. _ — . . -- --- -- - � <br /> i1 aulhonrr. Ihe relcase of my rebalo lo ihe vendor listed on Iho back of this form pending � <br /> approval o( the completed Backwater Prevention Device rebate packel hy Ihe City o1 Everett I <br /> � I <br /> I � <br /> � <br /> �� �� i <br /> ,�.--- , Z- � � - �, ; <br /> � <br /> S�gnaturc of Property Ovmer Date � <br /> �. __-..— - -- — - -- -- ( <br /> - - --- --- � <br /> i <br /> i <br /> � <br /> . y <br /> � <br />