Laserfiche WebLink
Backwater Prevention �Ievice Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (Cify to Pravide) <br /> Please complete both sides �f the form <br /> Property Owner Section: � I <br /> Property Owner Name: 1a co\co Fo••c.h P— <br /> �nstallalion Address: '�3 0� O'�c,� �cee-'t <br /> City: G�e(c_� Stale: Wh Zip: �Y�b \ <br /> Mailing Address(if dilferant): t�ao� \'�3�- 1-A1 �:Ef 73C� <br /> � City: �C:�1c\�r.� S18te: vJP Zip: q�$U3�� <br /> Email: 41'ros5c�nr����� Phone: (aa�) ? �S� —`�`� �� <br /> Total Cost to Install Device(from controcfor invoice):S oW�� �� <br /> I, lhe property owner, request to have the City of Everett Backwaler Prevention Device rebate check <br /> ' for the installatlon of the device at the above referenced property address be made payable to, and <br /> sent to,the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will not receive a rebate check directly from the City of Everett. <br /> 2. Assigning payment of lhe rebate to the vendor does nol exempt me from Backwater <br /> Prevenlion Device Rebate Progrem requirements. <br /> I aulhorize the rolease of my rebate to the ven ior listed on the back of Ihis form pending <br /> approval of the completed Backwaler Prevention Device rebate packet by the City of Everetl <br /> \ �. <br /> C `t -•-��, - �. � � <br /> Signature of Property Owner Date <br />