Laserfiche WebLink
4 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 />Property Owner Section: <br />Property Owner Name: <br />Installation Address:o�Z/y/ <br />City:y�✓�// _ State: Z< ' _ _ Zip: <br />Mailing Address (if different): _ <br />City: — State: -- — Zip:, - <br />Email: Phone: ( ) <br />Total Cost to Install Device (from contractor invoice): S 2`f�zL vo <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 />t <br />1. I will not 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 />A� is <br />Signature of Pro erty Ow Date <br />