Laserfiche WebLink
� Backwater Prevention Device Rebate Program <br /> Vendor Payment Option F�rm <br /> Project Numbe:: _ (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: __ 1���jn 4 �(.J�� �u�GG� _ <br /> 7—' <br /> Installalion Nddress: � �� _ __—_ <br /> City: �lil2� Slale:_��__Zip' 9A z0� <br /> Mailing Address (ifdi(lerenQ: <br /> City: State: Zip: _ <br /> Email: _ __ l�-Zl.LGLIiL�G1�?_��Phone: (yLS��.3—�� — <br /> (/ �p <br /> Total Cost to Inslall Device (lrom conlractor invoice): $ �n�� •I� <br /> --� <br /> I, the property owner, request to have the Ciry oi Everett Backwater Prevention Device rebale check <br /> for l+�e installation of ihe device at lhe above referenced property address be made payable to, and <br /> senl to. Ihe vendor sper.ified on lhe back o(this form. Ry reyuesling Ihe rebale check be made <br /> paya6le lo lhe vendor, I agree lo the following: <br /> 1 I will not receive a rebale check directly from lhe Cily of Everett. <br /> 2. Assigning payment of lhe rebate to lhe vendor does r.ot exempl me from Backwater <br /> Prevention Device Rebale Program reyuiremenls. <br /> I aulhorite the release o(my rebale lo the vendur listed on the back of this form pending <br /> approval of Ihe completed Backwater Prevenlion Uev�ce rebale packel by Ih� Gty of Everett <br /> < <-6'C \ �,�5-_�s- <br /> �� -Y�— — <br /> Si�'ialure o raperty Owncr Date <br />