2532 RUCKER AVE 2022-05-12 - Laserfiche WebLink

I ... .-. - ------- - -. _� ._ _ - - - . .__. _._- - - - ._.-� . - � . .._._ ___ ._.. ._----------------. _�. _- , . . . . . � .. � . .. . . . . . .. . . I � . � . . . . . , . . - . . . . �, . .. � I 1 -Backwater Prevention Device Rebate Program ; ; � � Vendor Payment Option Form ' ' ; � � � ; � Proiect Number. (City fo Provide) ! I _ . ' � Please complete both sides of tP�e fortn ; � � : Property Owner Section: •.j � : -- — i ; Property Ownor Name: --1�_ 1(.�L Y Y`C LC- _ ; � Inslallation Address: �i5�� ^ i , City:�1A2-`T� State: ��!Zip: ��v� � 1 � Mailin3 Address(if diNerenQ: � ' Ciry State: —ziP: Email: Phone:�P �07� '�� I Total Cost to Install Device (from confractorinvofce):$_��' _�� - i I,Oie property owner, iequest lo have the City ot Everett Backwater Prevention Device rebate chedc � ior lhe installalion of lhe device at the above reterenced property address be made payable to, and senl to,'the vendor specified on the badc of this Form. By requesling the rebate check be made payable to the vendor, 1 agf�to Ihe following: i 1. I will not receive a rebate check directly from the City of EvereH. '� � 2. Assigning payment of the rebate ro the vendor does not exempl me from Backwaler � Prevention Device Rebate Program requiremeMs. I aulhorize,the release o(my rebate lo the vendor listed on the back of this torm pending approval of Ihe completed Backwater Prevenlion Device rebate packet by the Ciry u(Everett ' i � , I �P/�.2,C1�-� �P-/l"��Fi i I � SignaWre ot Property Owner Date � I I � i i � � .