Laserfiche WebLink
i <br /> ; <br /> Backwater Prevention Device Rebate Program , <br /> Vendor Payment Option Form , <br /> Project iJumber. (Ciry to Provide) ' <br /> ' <br /> Please complete both sides of the form j <br /> Property Owner Section: <br /> _ � <br /> � h /d " <br /> Properiy O�vner Name: �n c rn o --- <br /> Installalion Address: �PI�J �Zk�-�- '�� � <br /> Ciry: �✓Ef2�� State: �a Zip: 9B2o� ; <br /> I <br /> Mailing Address (!f drfferent)' — — <br /> City: State: Z�P� - � <br /> Email: Phone: ( ) <br /> Total Cost to Install Device (from contracforinvoice): 5 02`�3�SS <br /> i <br /> L - — i <br /> I, the property ovmer, request lo have the City ot Everett Backwater Prevention Device rebale check <br /> for the instaila6on of the device at the ahove re(erenced properiy address be rtiade payable to, and <br /> sent to, the vendor specified on the back ot this form. By requesting the rebate check be made <br /> payeble to the vendor, I agree to the following: � <br /> , <br /> 1. I�vill not receive a rebate check directly from the Cily of Everett. � <br /> 2. Assigning paymenl of the rebale to the vendor does not exempt me from E3ackwater ; <br /> Prevention Device Rebalc Program requiremenls. ` <br /> -- --- — — ------ --- <br /> I authorize Ihe release of my rebate to lhe vendor listed on thc back ol lhis form pending ; <br /> approval of ihe completed [3eckwater Prevention Device rebate packet hy lhe Cily of Everell � <br /> �- �.�� '° � a0 " '� � <br /> Signature of Property Owner Date � <br />