Laserfiche WebLink
Backwater Prevention Device Rebate Proqram <br />Vendor Payment dption Form <br />Project Number. (City fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: (� R_q�L h V R Ni� �. K�/Pr 1 G". — <br />Installation Address: � I�.� 3� I t I�C"T �%��«� �' <br />City: �U (ZL" 1� I _ State: /� ( `� Zip:��b I — � � � � <br />Mailing Address (il dit(erent): <br />�i�y; State: <br />Email _ - — Phone: (42� _a.5 Cj - 6�65 <br />Total Cost to Install Device (from con7racfor invoice): S___�1�.8 <br />I, the property owner, request to have the City o( Everett Backwater Prevention �evice rebate check <br />f�r the inslallation of Ihe device at Ihe above referenced properly address be made F.iyable to, and <br />:ent to, lhe vendor specified on the back of Ihis form. By requesting•the rebate check be made <br />payable lo the vendor, I•agree lo the following: <br />1. I will not receive a rebate check directty from the City ot Everett. <br />2. Assigning payment of the rebate tc lhe vendor does not exempt me from Backwater <br />Prevenlion Device Rebale Prograin requiremenls. <br />I authorize the release of my rebale to the vendor listed on lhe back of this form pending <br />approval of Ihe completed Backwater Preven6on Device rebate packet by•lhe City of Everett <br />�o � ��� �� �- �- s <br />�1, a � <br />Signature of Property Owner �ate <br />