2119 MCDOUGALL AVE 2022-05-03 - Laserfiche WebLink

OLBackwater Prevention Device Rebate Program Vendor Payment Option Form Project Number: _ (City to Provide) Please complete both sides of the form Property Owner Section: Property Owner Name: G2.vn% Mi6 + 5A z"� ri)ini52 r '"� f S Installation Address: Gil% /"Ic_w�_4:�4 City: F,V�. State:. W_ Mailing Adds_;: td different); City: State: 9az") Email: [A(40A 11 u (01 �Otll'A;%. GCIM Phone: ((06) 2-51— .3%V/ Total Cost to Install Device (from contractorinvoice): $ I "I I • �t� I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check for the installation of the device at the above referenced property address be made payable to, and sent to, the vendor specified on the back of this form. By requesting the rebate check be made payable to the vendor, I agree to the following: 1. 1 will not receive a rebate check directly from the Cilv of Everett. 2. Assigning p•:ymenl of the rebate to the vendor dor s not exempt me from Backwater Prevention Device Rebate Program requirements. I authorize the release of my rebate to the vendor listed on the back of this form pending approval of the completed Backwater Prevention Device rebL.:: packet by the City of Everett 7 /`/ zG /s Signature of Property Owner Dale L;