Laserfiche WebLink
i <br /> i <br /> � <br /> Backwater Prevention Devii;E: Rebate Program ' <br /> Vendor Payment O��iion Form ; <br /> Pruject Numbe�: (Cdy to Fiovfde) ' <br /> I <br /> ; <br /> ?iease com�ic,e ao�ii sides o� tiie form ; <br /> i <br /> Property Owner Section: <br /> �? Donavan Rieger ' <br /> roperty Owner Name: _ _ �� <br /> �,nstauation Address: 2z29 Rockefeller Ave <br /> .ity Everett State: WA Zip: 98Z01 <br /> f <br /> Malling Address(i(diNerenl): ! <br /> City --- — State: _ 2ip, i <br /> Ema�r donavan_rieger@hotmail.com Pnone � 425 239 5633 ' <br /> Tclal Cost to Install Device (hom contractor fnvoice): S - <br /> I, lhe property owner, request to have the Cily o( Everetl Backwate� Prevention Device rebate check <br /> (cr Ihe inslallation of Ihe device at lhe abcve reterenced property address be mado payable to, and <br /> sent to, tho vendor specified on ihe back o(thls form. By requesting t�tie rebale check be made <br /> payable ro ihe vendor, I agree to lhe tollowing: <br /> 1 I will nol receive a rebale check diredly from the City of Everett I <br /> 2. Assigning payment o(the rebate to the vendor docs not exempt me irom Backwater ' <br /> Prevention Device Rebale Program requirements, <br /> I aulhonze the release of my rebate lo the vendor listed on the back of Ihis form pending ; <br /> approval of Ihe compleled Backwater Prevention Device rebate packet by lhe City of Everetl <br /> Dor,r�� �e�el� <br /> 04 /15/2015 <br /> i <br /> Signature of Property Owner Dale � <br /> I <br /> I <br />