Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projed Number: _ (City to Provide) <br /> iPlease complete both sides of the farm <br /> i <br /> Propehy OwnerSection: <br /> ��' . -- -- �_- --- , <br /> Property Owner Name: ��q � 1 E SZE'�'t <br /> �� � Instaliation Address:� �— 'Q � ' , <br /> city: � ., state: ��" _zip: °l 81-0 J <br /> � .. • . . . ."l.` _ . .. . � . . . .rF <br /> � Mailing Address (i(diHerent)� <br /> I �Gity: . State: - ; 2ip:_ . - �.; <br /> i `..:'` '; <br /> Einaii: Phone: ( ) <br /> .a:r- . �r ' <br /> t � Total Cost to In�tall Device:(/rorn contracforinvoicej:S. �• ' `' ��" <br /> i <br /> � ' 'i::;+. ' . � <br /> . . . . , . . ':::�i'+ �i. P�. . . . . .. .. � <br /> � 1,th�e property owner;request'to have the City of Everett Backwater Prevention Device rebate�check <br /> for the installation of'fhe device at the above referenced propeAy address be made payable to, and <br /> , senEto, the vendor specified on�lhe back of this form. 8y.requesting the rebate check be made <br /> pay'abie to the vendor, I ag'ree to the followingi . � ' <br /> �,", d, I will nol receive a rebate.check direcQy from lhe City ol Everett. <br /> � � ��2. Assigning paymenl of the rebale lo the vendor does not exempt me'from Bac,icwater <br /> � Prevention Device Rebate Program requirements.� <br /> i , . <br /> ` I authorize the release ot my rebate to the vendor Iisted on the back of this form pending <br /> i approval of the completed Backwater Pr.evention Device rebate:packet b'y the Cily of Everett. <br /> i _ <br /> I <br /> I ,tei'T_ <br /> Signature of Property Ovrner Date <br /> il <br />