Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> Vendor Payment Option F�rm <br /> Project Number: __ (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> PropertyOwner Name:�� 1 �l� �- ��ti� �G� T�" <br /> Installation Address: 'P�7 �«ln Y—�'�— <br /> City:LL�'�'�/`- State: W`�__Zip� q�� I <br /> Mailing Address (il diHerent): _ ____ <br /> City: State: Zip: <br /> Email:�CW� ��v�a.V- � '-Vt'vC�i�2-V'• C-OP�1Phone: (��.��3r1'-�cr)'z, <br /> Total Cost to Install Device(Irom confractor invoice): S_�`�1 U q� <br /> I,the property owner, request to have the City of Everelt Backwater Prevention Device rebale check <br /> for the installation of the device at the above referenced property address be made payable to, and <br /> senl to, Ihe vendor specified on the back of this form. By requesling the rebate check be made <br /> payable lo the vendor, I agree to Ihe following: <br /> 1. Pwill nol receive a rebale cher_k dir.clty from the Cily of Everell. <br /> 2. Assigniog payment of lhe rebate lo the vendor does not exempt me from 6ackwaler <br /> Prevenlion Device Reoate Program requirements. <br /> I authorize the release of my rebate to the vendor listed on the back o(Ihis form pendmg <br /> approval o(lhe completed Backwater Prevention Device rebafe packel by the City o( Everett <br /> ��������._ �� rr r s- <br /> �ignalure o(Property Owner • Date <br />