Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form� <br />Project Number: (Cify fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Nam <br />Installation Address: <br />City: �j��,"� Slale: �__ Zip:___ C�p_�___ <br />Mailing Address (il diKerent): <br />City: Stale: __Zip: <br />Email:�� � _ ,� ( hone: {�-�j��—��� <br />Totat Cosl to Install Devicc (from conhactor invoiceJ: S <br />I, the property owner, request to have the City ot Everelt Backwater PreveNion Device rebale check <br />(or the installation of ihe device at the above referei�ced property address be made payable to, and <br />sent to, Ihe vendor specified on the hack of ihis (orm. By reques�ing the rebate check be made <br />payable to Ihe vendor, I agree lo lhc folfowing: <br />7. I will not receive a rebate check directly irom Ihe City of Everelt. <br />Z. Assigning paymenl ol lhe rebale lo the vendor does not exempt me from Rackw�ler <br />Prevention Device Rebate Program requiremenls. <br />I authorize thc release of my rebate to the vendor listed on the back o( this (onn pending <br />approval o( the compleled Bar,kwater Prevention Device rebate packel by Ihe Cily ot Everett <br />r <br />�...1 V�\ �2 � 20 � 2UI'-� <br />Signalure of Property Ovmcr Dale <br />