Laserfiche WebLink
. i <br /> Backwater Prevention Device <br /> E� Rebate Program ( <br /> i <br /> Fur internal Use: f'ra�cr.t Murnficr � <br /> Vendor Payment Option Form <br /> Please complete hoth sides of the form ! <br /> Property Owner Section (picase print): � <br /> � <br /> - — ; <br /> 1�,"1 ��.�"� ------ ------- --- --- + <br /> Froperty Oemer Namc <br /> 1la.ZE? k:��1LcS 4Qz,�.''--- -- — — -- - � <br /> i <br /> Properly Address Ci(y Stale Zip � <br /> ; <br /> A!tema!e ictailing Addres, Clly Slate 7.ip � <br /> . ___._ ._ — — --- -- - � <br /> Phone — [mad ' <br /> I, the Property Owrer, reyuest lo havc the City af Everett F3ach�vater Prevention Uevicc: <br /> rebate check for ihe installatiun raferenced at the Property �ddress he made �ay,�hle ' <br /> te, and sent to, thc Vendor. f;y requesting the incentive/rebate check be made payable I <br /> tc� the Vendor, I agree to thc (olluwing i <br /> 1. i will not receivr. a B�ckw�ter Prevention Device rebate check direclly frc�m the ; <br /> City of Everetl. � <br /> Z Assigning paymenl uf lhe [3ackv�alzr Prevention Device rabale to ihe Vendor I <br /> dor.s nol exempt me from E3ack�vatcr Prevention Devir.e Rebate f'roqram � <br /> requirements. , <br /> � <br /> l <br /> I aulhorite the rclease of my rcb�ile to Ihc Vendor Iisled on payc hti�o of �his funn ; <br /> pending approval of lhe compleled L{�ckn�ater Prevention f)evir,e reUule p�irk�ge by I <br /> the Cily of Everetl I <br /> � <br /> - - --� �n.� �Lt,t c���- - ���.. ���`Y ( <br /> � � <br /> Signaluie o(Pioperty O�vner Uate <br /> Pa_�c 1 0l 2 � <br /> iv:vici�d 9'3,'ZD i4 <br />