Laserfiche WebLink
� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. _ (City fo ProvideJ <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Ovmer Name: Y ��(!,� �I� ` _ _ �.cl.� � � � - <br />Installation Address: _�� K-VZ-K__p• f r 1-"� - <br />n' r <br />City���%� -L-- State: �i��- 2ip: 7� Z v� <br />Mailing Address (il diHerent): _ _ _ —. <br />City: --- _ Stale: ------ Z�p' _ <br />EmaiL• __ _ �_ -- <br />Phone:{�`?�_�5�= �u7�" <br />���� �— <br />To�al Cost to Install Device (from confractor invoice)� S�LC.:L• <br />i, the property owner, request to have the Gry of [vereU t3ackwater Prevention Device rebate check <br />for the installa6on of the device at lhe ahove referenced property address be made payable to, and <br />sent to, the vendor specified on lhe back of Ihis form. By requesting lhe rebale check be made <br />payable to the vendor, I agree to lhe tollowing� <br />1. I will not re.ceive a rebate check direclly from the City oF Evorett. <br />2. Assiqning payment of the rebate to lhe vendor does nat exempt me from Backwaler <br />PreveNion Device Rebale Program requiremenls. <br />I aulhorize Ihc iclease of my r�bate to the vendor hsted on the back of lhis form pendiny <br />approval of the completed F3ackwater Prevention Device rebate packel by the Cily ot Evere t <br />�S �\. \\ � � � <br />Sionature of Property Owner Date <br />