1627 OAKES AVE 2022-05-03 - Laserfiche WebLink

i I I ; Backwater Prevention Device E � � Rebate Program — I IFor intcrnal Use: Project Number: � — ------- Vencior Pa�yment Option Form � ►'lease complete both sides of the form � Property Owner Section (please print): i — — � --- — ---- i ---�,�_� 5��,�,� Property Owner Name — _lS0 Z� _C�vr�s__ G t)t.k.t l`l' 1��—_L�Z �L- Property Addre,s ' �i y State 2ip � —L�O�� _ � o-t�_ U/� c�L�Z T(� , iAltemate Mailing Address City Slate ��p � �-1��(.?7 Lu�L��,-��G� . Ct�� Pnone Emaii � --J � I, the Property Ovmer, request to have the City of Cverett Backwater Prevention Device rebate check for theiinstaliation referenced at the Property Address be made payable to, and senl to, the Vendor. By requesling the mcentive/rebate check be made payable to the Vendor, I agr le to the (oliowing: 1. I �vill not receive a Backwater Prevention Device re6ate check directly from the City of Everett. 2. Assigning payment of the dack�vater Prevention Device rebale to the Vendor does not exempt me (rom Back�vater Prcvenlion Device Rebate Program requiremenls.� I aulhorize the release of my rebate to the Vendor listed on page iwo o(this form ' pending approval oF th� completed Backwater Preventinn Device rebate package by the City of E erel � � � i / � ✓� �� Signature of PropeiAy Owner Date I i Revised 9I3i2014 Pane 1 of 2