Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (City to Proi�ide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> � Property O�vner Name: �Gf i/I � l� ��P�dJU1G���U� — <br /> � InslallationAddress Q� ���'S �ve <br /> I City: (—j,iE l�� Slate' �Zip:9�D—CI � <br /> � <br /> � Mailing Address(il diNerent): <br /> , Gity: Slale' _Zip: <br /> I Email: ���Qw�C .��?�_dP� Phone (�/���5� '�9'� I <br /> Total Cost to Install Device (bom contracforinvoice): 5 ___ I <br /> I, the property owner, request to have lhe City o(Evemtt Backwater Preventior Device rebale check <br /> tor lhe installalion of the device at the above referenced propeAy address be m?de payable to, and <br /> sent to, the vendor specified on Ihe back o(this form. By requesting lhe rebate check be made <br /> payable to lhe vendor, I agree to the folloe�inc�: <br /> 1. I �vill not receive a rebate check direcUy Irom lhe Ciry o( Everetl. <br /> 2 Assigning payment of the rebate lo the vendor does ��ot exempt me from Backevater <br /> Prevention Device Rebate Program requirements. <br /> I authonze the release of my rebate to the vendor lisled on.ihe back o(lhis form pending <br /> approval of the completed �ackwaler Prevenlion Device rebate packel by the City of Everelt <br /> �� - , � <br /> '� � <br /> %,� � .!'r 5' -/3 �is <br /> Signature of Property O�vner Date <br />