Laserfiche WebLink
Backwater Prevention Device Re6ate Program <br /> � Vendor Payment Option �orm <br /> Project Number: (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section; <br /> Properly Owner Name: I l ���1�\� <br /> Instatlation Address: ��� � 1 ) -+ , <br /> City:����t�'t� State:�__Zip:_�p��� <br /> Ivlailing Address(if diHerenf):�� �O� � � g I <br /> City: OC"� • i� Yw�� State:�l�—Zip: ����� I _ <br /> Email: V M 11�' �`PA�l`��(���'i l (.�O M Phone: (�L����' ��5� <br /> Total Cost to Inslall Device (from confractor invoice): $ <br /> I,the property owner, request to have the City ot Everetl Back�vater Prevention Device rebate check <br /> for the inslallation of the device at the above referenced property address be made payable to, and <br /> sent to,the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable lo the vendor, I agree lo lhe following: <br /> 1. I will not receive a rebate check directly from the City of Everetl. <br /> 2. Assigning paymenl o(the rebale lo lhe vendor does nol exempl me irom Backv�ater <br /> Prevenlion Device Rcbate Pragram requiremenls. <br /> I authorize the release of my rebale to the vendor listed on the back of this form pending <br /> approval o(Ihe compleled Back�vater Prevention Device rebale packet by Ihe City of Everelt <br /> i <br /> � �'" I J <br /> Signat r of Property Owner Dale <br />