Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Vendor Payment O�tion Form <br />Froject Number: _ (Cify fo Provide) <br />Please complete both sides of the form <br />Properly Owner Section: <br />Property Owner Name: <br />Installation Address: l L) v �f �-d <br />City: i�V [�d� "i'� Slate: <br />Mailing Address (if diflerenQ: <br />Cily: _ Slate: _ __ Zip: <br />Email: a S� �� �d�li._GDM Phone: (�r�,��J��S <br />Tolal Cost lo Install Device ((rom con(ractor invoir,eJ: $__�_��p�� <br />I, the properiy owner, requesl to have Ihe City oi Everett Backwater Prevention Device rebale check <br />for the inslallalion o( the device at the above re(erenced property address be made payable ro, and <br />sent to, Ihe vendor specified on lhe back of this form. By requesling lhe rebale check be made <br />payable to the vendor, I agree to the following: <br />1. 1 will not receive a rebalo check direcUy from Ihe Cily of Evercll. <br />2. Assiyning payment of the rebale to the vendor does not exempt me (rom E3ackwaler <br />Prevention Device Rebate Program requiremenls. <br />I aulhorize lhe release of my rebale to the vendor lisled on lhe back of lhis form pending <br />approval of the completed Backwaler Prevenlion Device rebate packet by Ihe City of Everett <br />��-- �- <br />5ignalure of Property Owner <br />�/oJ8//.3' <br />Date <br />