Laserfiche WebLink
Backwater Prevention Devi�e Rebate Program <br />�• Vendor Payment Option Form <br />Project Number: (Crty fo Provide) <br />Please complete both sides of the form <br />Properly Owner Section: <br />Property Owner Name: <br />Installation Address �L C�v / t _�( �NI [�t C _ <br />City: �, /' 1- State: �� Zip: y�.z v/ <br />Mailing Address (ildilferen!): <br />City: Stale: Zip: <br />Email: 0.'@ /' f � GcC�00 CUf� Phone: (�/� ��" D/v�i <br />r <br />Total Cosl to Install Device (trom con racforinvoice): $,��5. (oCd <br />I, the property owner, request to have the City o1 Everelt Backwater Prevention Device rebate check <br />for lhe insi:Wllation of the device al lhe above referenced properfy address be made payable lo, and <br />sent to, the vendor specified on the back of Ihis form. By requesting lhe rebate check be made <br />payable to lhe vendor, I agrec lo the follovding <br />1. I will not receive a rebate check direcpy from the City of Everelt. <br />?. Assigning payment ot the rebate to Ihc vendor does nol exempt me from Dackwatcr <br />Prevention Devicc Rebate Program requirements. <br />I aulhorize Ihe release ot my rebate lo the vendor listed on the back of this form pending <br />approval of Ihe completed Backwater Prevantion Devicc rebale packet by lhe Cily of Everott <br />- " - � � <br />.� ��+ . �"/' <br />�� �- . �/C� ��-� 3 /L � <br />Sign�t of Property wner Date <br />