Laserfiche WebLink
i <br /> ! <br /> i <br /> �Backwater Prevention Device Rebate Program <br /> Ve�dor Payment Option Form <br /> Project Number. (Cify to P�avide) ' <br /> i <br /> ; Please complete both sides of the form <br /> Property Owner 5ection: <br /> - � ! <br /> ' � i <br /> Property Owner Name:���t,� � � l,�.V �p � <br /> i J 1 i <br /> InstallalionAddress: ( ���1 ��D�a I <br /> c�������2�cr��1, s�aie: I. ���- ziP. cr5� Q�G� � � <br /> �-. - 1 i <br /> Maiiing Address(il di(lerenQ: �1� � �t�,��� n'�-- I <br /> c�ry: ��c-��rnr�v,d-S st�t�: W �" z�p: Qt��z� � <br /> EmaiL• ��y,�( 1Zj,Vy�p .�,� ' ,L Co�P,hone: (�(z�"")`1 b ��1�.0 <br /> Total Cost to Inslall Device(from conlracforinvolce): $ <br /> I,the property owner, roquest to have the City o(Everett Dackwater Prevention Device rebate check , <br /> for the Inslaliution o1 the device at the abovc referenced property address Oc rnbde payable to,and <br /> senl lu, the vendor specified on lhe back of Uiis fo�m. By requesting lhe rebale check hn made <br /> payabie lo the vondor,I agrco lo the Ioilowing: <br /> 1. I will not recelva a robate check dirQcliy from the Cily of Everett. <br /> 2. Assigning payment of fhe rebate to Ihe vendor does no�r,xcmpl mc fwm Backwaler <br /> Prevention Device Rebale Pragram requiremenis. <br /> I aulhorize Ihe release o(my rebale to the vendor listed on Ihe back ol this(orm pending <br /> approval o(Ihe comploted Buckwater Pravenlion Device rebato packet by Ihe Ciry of Everell <br /> �-1-�e. �L0.1�" 1, l`a_ <br /> Signaturc of PropcAy Owner Data <br />