Laserfiche WebLink
i <br /> Backwater Prevention Device Rebate Program <br /> T Vendor Payment Option Form <br /> Project Number. (City to Provide) <br /> ?lease complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ✓i cf�/ M�„y�;y, e� <br /> Installation Address: /y/3 /2����el�j/P/ A�G <br /> City: fveirfJ� State: r✓A' Zip: vssZ�J <br /> T <br /> Mailing Address (il dil(erentJ: � `� 3 H S �6G �k P L ��r <br /> c��y: � �au�\ Stale: w/� z�P: `t r� !q <br /> Email: [�I ? J��1-o r����ua�1 . t.n�� Phone: (y�5) �j� GG �!� <br /> � <br /> 'i otal Cost to Install Device ((rom contractorinvoice): S '�,,So o. � I <br /> I, the property owner, request to have lhe Ciry of[verett�ackv�ater Prevention Device rebate check <br /> for the installalion of the device at the above reterenced property address be made payable to, and <br /> sent to, the vendor specified on the back of Ihis form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will nol receive a rebate check directly from the Cily of Everett. <br /> 2. Assigniny payment of the rebate to the vendor does not exeinpl me (rom Backwater <br /> Prevenlion Device Rebate Frogram requirements. <br /> I authr,rize the release of my rebale lo Ihe vendor listed on the back of�his form pending <br /> appruval of th�� completed Back�vater Prevention Device rebate packet by lhe City of Everell <br /> � ,e�,��;i�� >�.�:�3/iy <br /> � <br /> Signature of roperty OwePr Date <br />