Laserfiche WebLink
� <br /> I <br /> i <br /> i <br /> Backwater Prevention �evice Rebate Program <br /> Vendor Payment Option Form <br /> Prcject Nur�be�:__ __(City to Provide) <br /> Please complete both sia�es of the form <br /> Property OH�ner Section: <br /> Property O�•mer Name: �( 'n�} L4.-c,{� . �(f- - --- --- —A� <br /> Instailation Address: <br /> � <br /> � Ciry: -_ - - State: _Zip: _— <br /> h-ta!IirgAddress (i/drNerenlJ: __ __. <br /> City: _ Statc� _Zipt___ <br /> Emaii: — - ---,Phone� ( ) <br /> , Total Cost to Install f�evice (fiorn contr�cforinvoice): $ _ <br /> i <br /> L— ----' ---- .._ — --- - - ---- — �. <br /> I, the property otivner, request lo I�ave the Cily of Fvereit Dac'�cv.�ate• Prevenlion Device reba:e check <br /> for the installation cf lhe device at the abovo re`erenced property r fdress be made payable to, and <br /> sent to, lhe veeeior specified on'I:e back of this fonn. By teyuestiny the rebs;e check he made <br /> pa;�able lo the vendor, I ayiee to lh� (ollowing: <br /> 1. I�viil nnt rr.ceive a rebate check direGly trom Ihe City nf Everett. <br /> 2. Assigning payment of Ihe rebate to the vendor does not exempt n;t; 5cm Pac.w��fcr <br /> Pr�venlion�evice Rebate Prcgram requirements <br /> I auUinii,:o the release ot my rebate to Uie vendor lisled on Ihe back o(this fonn pending <br /> approval of the completed Backwater Prevention Dovice rebate packet by the C�;y of Everett � <br /> j �_--- - ,. <br /> -!„`_ ' — - �'r' , ',� /D - /e - � <br /> S nrature of Pro� C?wnri Date <br />