Laserfiche WebLink
� <br /> � Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Number: _ �� � (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: �I�NLC �U.lf�[LdlL' lY/�is7!� <br /> Installation Address: (�� 0 �U.liR.�� <br /> City: ��__State: Ull�� --Zip:���'� <br /> Maiting Address (il dillerenl): _ _____.__ _ <br /> City: Stale:_ Zip: __ <br /> Emai1:�1LQ.�JI,b](oZ(% C�0�'�U � (�o�"�____Phone: �) F170 O y6� <br /> Total Cost to Install Device (from contractorinvoice)� 5 3��'1'• U� <br /> I, the property owner, request to have the Cily of Everett Backwaler Prevention Device rebate check <br /> t�,r the installation of the device at the above referenced property address be made payable lo, and <br /> senl to, the vendor specilied on the back of this form. 8y requesting the rebate check be made <br /> payable to the vendor, I agree to the follo�ving: <br /> 1. �will nol receive a rebate check direcUy from the Ciry of Everett. <br /> 2 Assigning payment of the rebate lo lhe vendor does nol exempt me from Backwaler <br /> Prevenlion Device Robate Program requirements. <br /> I aulhorize Ihe release of my rebate to the vendor lisfed on the back of this form pending <br /> approvai of the completed Backwater Prevention Device rebale packet by Ihe City of Everelt <br /> �� ICs�.�— �- i 3—� � <br /> Signalure o(PropeAy Owner �ate <br />