Laserfiche WebLink
��%^� Backwater Prevention Device Rebate Program <br />E,, Vendor Payment Option Forrn <br />ProJect Number. _ -------- (Gty to Piovidr.) <br />Please complete both sides of the form <br />Property Owner Section: <br />� - ---- --- --_ �— ,; — — I <br />IProperty O�vner Name -> 1(, Uc =_� ����� � I <br />' _��� /� ��� <br />Installation Address _S �� � !. � � I � <br />� — � n .-'�. � <� � � <br />I CitY' _ l' .v �G� {I __ Stale: %✓� Zip: <br />A9ad�ng Address (if dillereni): <br />City: -- State: -- - Z�P'— <br />Email _ Phone: ( ) <br />I Total,Cosl lo Install Dewce (Irom confracfor invoice): 5 ��� 3 �•``� `� __ I <br />—� __. <br />�---- -- --- --� <br />I, lhe prope�ty ovener, request to have lhe City of Everell 8ackwater Prevention Device rebale check <br />for the installation of the devir.e at the above referenced properly address be made paya6le to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check he made <br />payable to Uie vendor, I agree lo lhe following: <br />1. I wlll nol receive a rebate check directly fromdhe Cdy o( Everett. <br />Z Assigniny payment o( the rebale to 1he vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />- ----- --- — — -- __. ,i <br />I authorize thc release of my rebate lo thc vendor lisled on lhe back of this lorm pendiny <br />approval o( lhe compleled 8ackwatm Prevenlion Device rebale packet by the City of Everell <br />�'� ��`-`_ �,/N'I�L� ��I;) , <br />I Signature of Property Owner Date <br />� — — — - - --- --J <br />