Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> Vendor �'ayment Option Form <br /> Project Number ___________ (City to Pti��ide) � <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> IProperty Owner Name l��L-'IUin/ ��.4NCUG.� l� <br /> �I Installation Address: �33 Z - l�l n p 5 T� i <br /> ICiry: 6'ii�tvt/T State: w,.9-- ._ Zip: QQZa( <br /> � <br /> I Mailing Address (il dillerent): <br /> i <br /> ' City: Stele: Zip: <br /> I <br /> I Email: _ Phone: ( ) <br /> i <br /> Total Cost to Install Device (/rom contraclor invoir.e) 5__���oG•/ <br /> i` <br /> I, ihe property ovmer, requesl lo have the Cily of Everett Backwater Prevention Dwice rebale check <br /> (or the installation o(the device at Ihe above referenced property address be made payable to, and <br /> sent lo, ihe vendor specified on the back of this form. By requesling the rebate check be made <br /> payable to the vendar, I agree lo lhe(ollowing: <br /> 1. 1 will not receive a rebate check directly from the Cdy of[veretl. <br /> 2. Assigning payment of the rebale to the vendor does not exempt me from Back�valer <br /> Prevention Device Rebate Program requirements. <br /> II I aulhorize the release of my rebate to Ihe vendor listed on Ihe back ot Ihis form pending <br /> approval of the completed Back�vater Prevenlion Device rebate.packet by the City oi Everett <br /> � <br /> �il�u ' - . 3 -z3�r <br /> Signature of Property Owner � Dato <br /> �-- -- -- --- --- <br />