Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Number: ____ (City fo Providef <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Cwner Name: ��_�� _ �G� <br />Installation Address: _� �I7 �%N ��%r�— <br />Cily:��GLIC�� State:�Zip: % O � � <br />Mailing Address (il dillerenl): ���� ��/ � /�"1/L l Y C= <br />City:.L C � i�G�f Slale: �[/_� Zip: /�Z� <br />Email: nWt C.C��!LPrr C�o,�-�P .�d K-Phon�( r) 3�f�/�� z-� <br />�----- <br />Total Cost lo Install Device (/rom confracforinvoice): $ <br />I, the properiy owner, requesl to have �he Cily of Everelt Backwa(er Prevention Device rebale check <br />for lhe inslallation of the device al Ihe abovc referenced proper�y address be made payable lo, and <br />sent lo, �he vendor specific;d an Ihr hack of ihis form. 13y reyuesling lhe rebale check be madc <br />payable lo lhc vendor, I agree to the following� <br />1. i v✓ill not receive a rebale check directly from the City o( Everelt. <br />?. Assic�nmg p�yment of Ihe rebate to Ihe vendor does nol exempt me (rom Dackwater <br />Prevention Devicc Rebalr. Pro7ram i�quirements. <br />I aulhorize Ihe relcasc o( my rebatc to ihe vendor tisled on lhe back of ihis forrn pendiny <br />approvat of thr, rompleted 8�ickvdaler Prevenliun Device rebale packet by lhe City of Everell <br />��'�� % _ � �//� zQ/ <br />/��� <br />Signalure of Ptoperty Owner Date <br />