Laserfiche WebLink
Backwater Prev�nti�on t�evice Rebate Proc�ram <br /> Vendor Payment Uption 1=orm <br /> � <br /> , <br /> Pro�ect Number. (Ciry to Frovide) � <br /> i <br /> � <br /> Pleas�a complete both sides of tF�e f��rm <br /> � <br /> Property Owner Section: <br /> �I Properiy Owner Name: �2vrt,1�, �. Pa�V. '�-�l <br /> Installation Address: �� Z.,�P L�'�'�V.J�^'�` ✓��t,� I <br /> City: �V'��- State l�-�� Zip: Y ��'�3 � <br /> � <br /> I �vlailing Address (if diKerent): <br /> Cily: State: Zip' ! <br /> Email: Phone: (�)ZJ� U� Z- l���l <br /> � I ' / I �� <br /> �� <br /> � Total Gost to Install Device (lrom contractor invoice): S�8`"1� ' <br /> � _l <br /> I, the property owner, request lo have the City of Everett Backwater Prevenlion Device rebate check <br /> for the inslallation of the device at the above referenced property address be made payable to, and <br /> sent lo, the vendor speci(ied on lhe back of this form. By requesting the rebale check be made <br /> payable to the vendor, I agree lo lhe following: <br /> 1 I will no� receive a rebate check direcUy (rom the City of Everelt. <br /> 2. Assigning payment of lhe rebale to the vendor does not exempl me from Back;vater <br /> Prevention Device Rebate Program requiremenls. <br /> � I authorize lhe release of my rebate to the vendor lisled on the back of this form pending <br /> approval of the compleled Backvtaler Prevention Device rebale packel by lhe Cily of Everelt <br /> � �.rit ,���cr/��-- U' �c� ;C G' .2d/�i <br /> ; Signalure of Property Owner Dale � <br /> I <br /> ��- - _ ------ --- _ - --.. _ -- — <br />