Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. _ ___ (City to ProvideJ <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Nam��� CVL= .��Yi / y <br />Installation Address: ,�.�� �.P1i-.f�� K�� <br />City:�� Stale� LUIi�- ZiP' C�� ----- <br />Mailing Address (if diHerent) ��'f �/}� s//r1l2 ,�� �� <br />/J —' <br />Cily: /�7���� State: �� � Zip: �c�r� %� <br />Email �(/Illir�S(���.usi1, LOM Phone: ��y !,3�.i � y�i % <br />/ <br />Total Cost to Install Dcvlcc (Irom contractorinvoice): $ _ <br />I-- <br />I, the property owner request to have the Cily oi Everelt Backv�ater Prevention Device rebate check <br />(or the inslallation of lhe device at the above referenced property address be made payable to, and <br />sent tn, the vendor specified on the back ol this form. By requesting ihe rehate check be made <br />payabie to the vendor, I agree to the follnwing� <br />1 I will not receivr, a rr,bate check dtreclly from Ihe City o( Everelt. <br />2. Assigning paymenl ol the rebate to the vendor does not r.xempt me from Backwater <br />Prevenlion Device Rebate Program requiremenls. <br />I aulhorize the release of my rebate to Rie vendor lis(ed on lhe back of this (orm pending <br />approval ot the completed Backwater Prevention Device rebale packet by ihe City of Everelt <br />�_--'��=��' ,"�– _ �,�-�/� /�3v—f - <br />�-- <br />Signature of Property Owner Da�e <br />