Laserfiche WebLink
� Backwater Prevention Device Rebate Psogram <br />Vendor Payment Option Fann <br />Project Number: (City to P�ovlde) � <br />Please completa both sidas of the torn� <br />Property Owner Section: <br />Pinperty Owner Name: <br />� <br />Installation Address: a� S i �3'r�"�� / l'vQ ' <br />City: �iX� State: i✓� Z�p: � c� �� <br />Malling Address (il diRerenf): � D 4J�i� 7' l ' <br />ciri:Sn��v�.lr�.`e s�ata: �,/�-- z�P: `� g� `�' -• _ <br />Emall: J���� �"�^C4j'T ; N� C phane: ��li�� 7� Y <br />Tolal Cost lo Install Device (hom confrecfor invoicaJ: $ c� �t ��,• cl d � <br />!� <br />, I, lhe propeRy owner, request to have the Cily of Everett Badcwater PrevenUon Oevice rebale check <br />for lhe inetallaHon ol tfie device et the above referenced property address be mede peyeble to, end <br />sent to, lhe vendor spedfied on the back of Ihis fortn. By requesling the rebate check be mede <br />� payable to ihe vendor, I agree to the Following: <br />� 1. I wNl not receive a rebate check directly Rom Ihe City of � verefl. <br />2. Asslgning payment of the rebate to the vendor does not exempt me hom Beckweter <br />; Prevention Device Rebate Program requirements. <br />i aulhorize the release of my rebate to Ihe vendor Iisled on the back of ihia fortn penQing <br />approval of the completed Backwater PmvenHon Device rebate peckot by Ihe City of Everett <br />[� <br />Signeture of Proparty Owner <br />�%/!5'- <br />Date <br />