Laserfiche WebLink
� Backwater Prevention Device Rebate Program <br /> � Vendor Payment Option F�rm <br /> Project Number. (City lo P.rovide) <br /> Please complete both sides of the form <br /> � Property Owner Section: <br /> � <br /> Property Owner Name: _������f'�_X - ---- - - <br /> Installation Address: ��p�?;��G �f���� �' <br /> I City: �/.1/�.!'�� State:�Zip: �iQ�� <br /> Mailing Address(i(diNerent)' <br /> City: Slate: _Zip: <br /> � Email: Phone: ( ) <br /> Total Cosl to Install Device (from confractor invorce): S���� <br /> I, the property owner, request to have the City of Everett Backwater Prevenlion Device rebate check <br /> for Ihe installation of the device at the above referenced property address be made payable to, and <br /> sent to, the vendor specified on the back ot this torm. By requesting the rebate check be made <br /> payable to the vendor, I agree lo the following: <br /> 1. I will nol receive a rebate check directty from the Ciry of Everelt. <br /> 2. Assigning payment of the rebale to the vendor does not exempl me from Back�valer <br /> Prevention Device Rebate Program requiremenls. <br /> I authorize the release of my rebate lo the vencbr Iisted on the back oi this form pending <br /> approvai of the compteted Backwater Preveniion Device rebate packet by lhe City of Everett <br /> � ^ 7 � <br /> � � �- S'- /�" <br /> Signature oF Property O�vner Date <br />