Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number _ (City to. Provide) <br />Please complete both sides of the form <br />Proparty Owner Section: <br />Property Owner Name: �AR�H W Re9AW <br />Installation Address: 3 tJ o c�- kc)G-e-r-ei reA-tt4t)) )- <br />City: F::V,0r2e H- State: w A— Zip: <br />Mailing Address (if different): <br />City: Stale. Zip: <br />Email: brOttica 4LA, - P_Lo-3-<2!�bPhone:( per' <br />Total Cost to Install Device (from contractor invoice): $ �L9�%r 3 G <br />.I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. 1 will nnl receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevention. Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the completed Backwater. Prevention Device rebate packet by the City of Everett <br />Signature of Property Owner Date <br />