Laserfiche WebLink
Backv�iater Prevention Device <br /> Rebate Program <br /> For internal Use: Pru�ecl Nuinber: <br /> Vendor Payment Option Form <br /> Please complete both sides of the form <br /> Property Owner Section (please print): <br /> �i�GY� �'t LL' <br /> Pro �y Ovmer Name --- - ---- -----_ - – ----- i <br /> ��� �Pna,3�.a���'��_—�_-- 9�zdl---- � <br /> Property Address City Statc Zip <br /> ---- -- --------- — _ - .-- <br /> Altemate hiailing Address City Slale Zip <br /> _ – ---- <br /> Phone Finail <br /> I, the Property Ow�er, requcst to have the City of Everet� E3ack��✓ater Prevention Devire <br /> rebate �:heck for the inslallation referenced at the Property Address be made payable <br /> to, and sent to, the Vendor. By reyuesting the incenlive/rebate check be made payahlc <br /> to the Vendor, I agree to the (ollowing: <br /> 1. I will not receive a Backwater Prevention Device rebate check directty from the <br /> City of Everett. <br /> 2. .�ssrgning payrnenl of Ihe Backwater Prevenlion Device rebate to the Vendor <br /> does not exempt me from E3ac1<v;ater Prevention Devir.c; Rebnle Program <br /> ir quirements. <br /> I authorize the release of my reba(c tu lhe Vendor lisled on paye tevo of this (orm <br /> pending approval of the com�leted Backwater Prevention Device rebnte �ricka�e by <br /> th�� City of Everett <br /> � <br /> g�� s�/���r �. <br /> Siynah:rr. o(Properf�� Owr;er D;;�� <br /> Pan�� 1 bf 2 <br /> I:��viticd 9/312014 <br />