Laserfiche WebLink
! <br />f:la� 1G'�U? '9: OFAPI�SFFtOFFSSIOfJAI PHOTJ �2�3179969 <br />� Backwat2r Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Pro;ect Number _ <br />�c;ry ro Provr�c� <br />Please complete both sides of the forrn <br />Property Owner Section: <br />Propert/ Ov:ner Name: <br />InstaUation �ddress: <br />zzx rra <br />City: �,��e-�� Stafe � �"' Z!p: � � --- <br />hlalinc Add'ess (il drf�erentJ: o�s� �'{' �� � <br />City: ��� _ Slate:---l.l�v_YY- ZiP:�� <br />cmail: (�G�`St S J7 R D !CJ �t �fi �%► G!�l%Z Pho-:c ;� .��i' �2 � � ! <br />r M <br />Tolal Cost lo Insta9 Oev�ce (f�om ccnt�acrorinvoice): 5� y'1'7• <br />I, the prop2rty owner, request lo have lhe C:ty of Everett BacY.v.�aler Prevenlion Device rebate check <br />lor Ihe installation of the device at Ihe above referanced property zddress be made payable lo, and <br />senl to, U�o vendor specdied on the back ol Ihis (orm. By requostirg the rebate check be matle <br />pa,able �o lhe verdor, I agree lo �he following: <br />1. I will not rece�va a rebata check d�reclly from ihe City ot Everett. <br />2 �ssignina payment o( the rabate lo the vendor dces not exempt ms from Backwaler <br />Prcvention Device Rebale Program requirements. <br />�, I aulhorize Ihe release of my rebale to th� vendor lis[ed on the back of Ihis form pendiny <br />I apnroval of ihe completed Backwater Preven'ion Gewce rebate packet by the City of Evorett <br />� <br />/" <br />%�-�---� <br />� �— <br />Sigrature ot Property Ormer ��� 1� u�' "�' <br />3/�� /I�� <br />Date <br />