Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Pro�ect Number. (Ciry lo ProvideJ <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: �1�-`� i �S\ S ��^—' �l � <br /> Installation Address: ����a.�-S �-�.7.1u-- <br /> City: 7�)�fi State: W'�` Zip: � �a� � <br /> Mailing Address (if diHeren!): � ��'3 ���l lL '�C�- ' <br /> City:��A11_ntn�-�u.� State: ��'P'_Zip� � � �o y <br /> Email: v\Yl l�_ ����'. �-�0�-, C CT"'� Phone: �') �1� —�� �`� <br /> Total Cost to Inslall Device (Irom confractor invoice): 5��"�I • �U <br /> 1, the property o�vner, request to have the City of Everett Backv�ater PrevenGon Device rebate check <br /> for the installation oi the device at the above re(erenced propeAy address be made payable to, and <br /> sent to, lhe vendor specified on the back of this form. By requesting Ihe rebale check be made <br /> payable to the vendor, I agree to the(ollov+ing: <br /> 1. I will not receive a rebate check directly(rom the City o( EvcrelL <br /> 2. Assigning paymenl o(Ihe rebale lo Ihe vendor does not exempt me from Backwater <br /> Prevenlion Device Rebate Program requirements. <br /> I aulhorize the release of my rebale to ihe vendor lisled on thc back of this form pending <br /> approval of the completed Backwater Prevention Device rebale packet by the City of Everett <br /> �� I I � <br /> Signatur�of Prope �vner Dale <br />