Laserfiche WebLink
I <br /> I <br /> � Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> IProject Number._ (City to Provide) <br /> � <br /> � <br /> jPlease complete bo!h sides of the form <br /> I <br /> IProperty Owner Section: <br /> �i ------- -- --- <br /> Property O�vner Name: 1'Y�� c 1 f�c C � ft_� S�.�Gr <br /> I� /3Zz �Z <br /> Installation Address: UG�F 12 � v i� <br /> � City: Fv��T�State: w� Zip: �8'a0� <br /> Mailing Address(i(dillerent): l� � �(?�C /� 37 <br /> City: �ivNWDoQ State: �� Zip: !Q O �� <br /> ! Email:��n� ��/-�D42� M�. L'o�+2 Phone:(�lsj 7��'36/� <br /> � <br /> Total Cost to Install Device(from contractor invoiceJ: 5__�3�-grQ � <br /> � <br /> i I, the property owner, request to have the Ciry o(Everett Backxater Prevention Device rebate check <br /> for the installation of the device at the above referenced pro[+�rty 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 /> , payabie to the vendor, I agree to the following: <br /> � <br /> ' 1. I will not receive a rebate check directly trom Ihe City of Everelt. <br /> � 2. Assigning paymenl of lhe rebate lo�he vendor does not exempi me from Backwaler <br /> � Prevention Device Rebate Program requirements. <br /> � <br /> � <br /> � I authorize the release o(my rebale lo Ihe vendor listed on the back of this form pending <br /> � <br /> approval of the completed Backwaler Prevenlion Device rebate packel by the City of Everett <br /> � <br /> i <br /> � � Z I <br /> iSign ture oi Property Owner � -- — Dale i <br /> � �i_ <br />