Laserfiche WebLink
Backwater Preventiun Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (City to Provide) , <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ��1� <br /> Installation Address:�/.Q/���5 �• <br /> City:�L��T Slate:�__Zip:'�� -- <br /> Mailing Address(if diNerenf): _�I�` . —_ <br /> City: - --- State: -----ZiP'— -- <br /> Email: ���'���._��'l'�A��•LDI'1�� Phone: �Ifi3��_ ��� <br /> Total Cost to Install Device (Irom contractor invoice): $ ����� <br /> �. the property owner, request to have lhe Cily oi Everett Backwater Prevention Device rebate check <br /> i. the installation of Ihe device at the above referenced property address be made payable to, and <br /> sent to, lhe vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to Ihe vendor, I agree lo Ihe following: <br /> 7. I will not receive a rebate check directly from the City of Fverett. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevenlion Device Rebate Program requirements. <br /> I aulhorize the release of my rebale to the vendor listed on the back of Ihis form pending <br /> approval of ihe compleled Backwater Prevention Device rebate packet by the City ot Everett <br /> � 2 zs /s <br /> Signature of Property Owner Date <br />