Laserfiche WebLink
� gackwater Prevention Device Rebate Program <br />Vendor Payment Option F�rm <br />Project Number' _ __ (City fo Pravide) <br />Please complete b�ih sides of the form <br />Property Owner Section: <br />Property Owner Name: f/>,�G/SJ%i /�����'ryy��'� � C <br />Installalion Address: ?�S/'7 ._ �% , �'�'�`C— - <br />City: ��Uh�-o'; — State ���fl_'_ Zip _ �.�20� <br />Nlailing Address (i( r�i/ferenf): � /l � GS /��/( � �/ <br />City: �i q-�t/� Stale:�if/�� 7_ip. �'f'u�7�� ��77/ <br />-�/ <br />Email: �JP.hi,ir/��ii,f�'�9/��'n �Oi�^ Phone:(JO)hS�"�/LOJ <br />Tolal Cos'. to Install Device (Irom contractor invoice): 5 �.SoO.�' <br />I, the properly owner, request to have Ihe Cily of Everet ���r Prevention Device rebate check <br />for ihe inslallalion of the device at the above referenced property a�.. he made payable to, and <br />sent lo, lhe vendor specif ed on the back of this form By requesting ihe .�'e check be made <br />payable to the vendor, I agree to ,he following: <br />t. I will nol receive a rebale check directly from the Ci.y of Everett. <br />2. Assigning payment of thc rebate to ,he vendor dr .s not er.empt me from Cackwa�er <br />Prevention Device Rebale Program requucments <br />I aulhonze the release o( my rebate to the vendor listed on the hack o( this form pending <br />approval of U�e comp�eted ar,ykwaler Prever�tion Device rebate packel by the City of Everett <br />Si,gnature of Property O�vner <br />� <br />,�-/I .� � �.�� <br />Date <br />