Laserfiche WebLink
� <br /> . .. , .."„ '. !Jo. 1329 P. 5 f <br /> 1 <br /> � <br /> gackwater Prevention pevice Rebate Program � <br /> Vendor Payment Option Form � <br /> i <br /> , <br /> Projed Numbe r:i__`(��Y to ProvideJ i <br /> � <br /> � <br /> ?+ease complete bo:i� sides of ttie form �I <br /> Property Owner Sectlon: ! <br /> f <br /> i <br /> Property Owner Name:��^� m , b�� i <br /> /"'I w � <br /> / � �S �u G 11� ' <br /> Installatlon Address. .� � <br /> Crty G�J�P.I�Q� Slale: � 21p� a�� � i <br /> i <br /> MallingAdtlress(ntlllferent)�_��7 Z �,�-P.tlGr� /�}(, ��. i <br /> � <br /> cay: � dl�0'r►'�q swie: t <br /> ` ��zip: �.�� Z-Z , <br /> Emell:�tp�.�,� LZ a �il�,h•�j�,���p��Phone: {� 9S� i <br /> Total Cost to Inslell Device(Irom cw�hacror invaice):S 2� I � �,5� � <br /> .�_ � <br /> I,the property owner,requesl to have the Ciy o(Everett Backwatar Prevenlion Deviee rebate check � <br /> for Ihe installatbn of lhe device a!the abwe ieierenced property address be made payable lo, and ' <br /> sent tu,the ventlor spedlled on tho beck of Ihis lortn, gy requesting the rebato chedc be made <br /> payable to Ihe vendor, I agree lo lhe foilowing� � <br /> 1. I will not raceive a rebate chedc diiectly from tho Clty of Evorett. � <br /> 2. Assi Nn � <br /> g g peyment of ihe rebate to lhe vendor does not exempt me from Dackwaler ' <br /> Prnvention bevice Rebale Progrem requiremanfs. � I <br /> 1 authorize lhe rolea.se of my reAate to the vendor Iisted on the 6ack of Ihis form � I <br /> approvai of Ihe campleled�ackwater Preventlon �ovice rebete peGeet by!he Cfly�o(�Evorett I <br /> f <br /> � I <br /> ( # I <br /> �jzal�s � <br /> Sg hue of Proporty Owner Da�e ` <br /> i <br /> i <br /> � <br /> . � <br /> ---__ � <br />