Laserfiche WebLink
_ a__ � <br /> �^%�� Backwater Preventian Device Rebate Program <br /> Vendor Payment Option Form <br /> Pro�ecl IJumber _ _ _. -----_, (City to Prm�ide) <br /> Please complete bottr sides of the form <br /> Property Owner Section: ' <br /> PropeRy Owner Name:�GL��S U�[lr�Clt�.��— � <br /> Installation Address �l7_1 l�—L_c2 �� I <br /> iCitY: ���',��'Tl State' ��—Zip:_�,�a0_1-- �i <br /> I h1ailing Address(i(diflerent): I <br /> City: Stale: ZiP I <br /> Email. Phone:�—vZs � <br /> Tota�Cost to Insta�� Device (�rom conrractor invoice): S 'a 3L-��� <br /> I, Ihe property owner, request lo have ihe City oi[verett Back�valer Prevention Device rebate check I <br /> (or the inslallation of ihe device al the above referenced property address be made payable to, and <br /> sent to, ihe vendor specified on lhe back of Ihis form. Dy requesling the rebate check be made <br /> payable lo the vendor, I agree to the following: <br /> 1 I will not receive a rebate check dueclly (rom lhe City of Everelt <br /> � Assignmg paymenl o(the rebale lo the vendor does noi exempt n��e frcm '3,ukwater <br /> F'ievenlion Dewce Rebate Program requiremenis. <br /> -------- -- — – _ — I <br /> I aulhorize ihe release of my rebate to the vendor listed on ihe back of this form pending <br /> approval of lhe completed [iack�vater P�evenGon Device rebate packel by Ihe City ot Everett <br /> i% -� �� <br /> ��' �/ <br /> � / �/ --71/� <br /> ��/1'el� �lN� � l?/i` � — <br /> Sigrfature of Prnperty Owner Dale <br /> _ __ -- — — -- ' <br />