Laserfiche WebLink
; <br /> � Backwater Prevention Device Rebate Program � <br /> Vendor Payment Option Form <br /> Project Number: _ �City f0 ProvJtle) � <br /> 1 <br /> � <br /> Please complete both ;fdes of the form ; <br /> Property Owner Section: <br /> i l • <br /> PropertyOwnerName ..�-i�itr'$bq --- � <br /> Installetion Address._�L(t �� �.�µ� � <br /> I ���' G�._Slate �41.� 2ip:_JY 1'0/ . <br /> Mailing Address(ifdrNerenl):_ <br /> City: �� Stzte: <br /> - Zip:�. <br /> Email� � rus�.��p,� n,��/', L . IttT _ Phone:��3ff_�sy�,,�0/ . <br /> =-lf L� <br /> Tolal Cost to Install Dovice (lrom cr�nlracta lnvaceJ:5 <br /> L the property owner,request to have the Ciry oF EveroM Backwater Prevention Devlco rebate check ' <br /> tor the Inslallation of the devi�et the above roferenceA property address ba made payable lo,and ` <br /> senl te: the ventlor specified on Ihe Gack of this fonn 6y roquesnng Ihe rebate check be made <br /> payable to the vendor, I agree to the(ollowing: ' <br /> 1 I wlll not receive a rebate Check directly from the Ciry of EveretL I <br /> i <br /> 2 Ag��9�i�9 peyment of the rebate to Ihe vendor daes nol ozempl me fran Bockwater I <br /> Prevenlion Device Rebate Program requirements ! <br /> I aulhorize the release of my�ehata�o the venqor li;led on the back oi ihls form pentling � � <br /> approval nF the comple�ed Backwater Prevention Deulca rebate packat by the Clty ot Everetl <br /> i <br /> i <br /> � �� 13 �.`�^� <br /> � Slgnat ire of Property Owner � <br /> Da�e <br /> L. - - -- ._. _ - - - .__ - - _-I <br /> ; <br /> "`;"O1�d TOc_b eSd G�p�w°�ci SR�£T Si(3?-O2-IJyf <br />