Laserfiche WebLink
i <br /> i • <br /> I <br /> k3ackwater Prevention Uevice Rebate Program <br /> Vendor PaymE;�nt Option Form <br /> I <br /> iProject Number. _ (City to Provide) <br /> i <br /> I <br /> ; Please complete both sides of the form <br /> � property Uwner Section: <br /> i <br /> i <br /> � Prouerty Owner Name:�o S 6 � . �ois T,Z��i`S <br /> � 2 5 /5 -�� ST���7 <br /> Installation Address: � � <br /> II City: � ✓G��T j Stale: (N�� Zip:��z � / <br /> I <br /> � Mail�ng Address (i(differentj: <br /> I City: State:_ Zip: <br /> , Email:�o�• � �.`�AS•MK�@�/zo%/.�ot1 Phone: ��S 31� —c�¢Z� <br /> �i Tolal Cosl to Inslall Device ((rom contractorinvoice): $__o2`f3j•�� <br /> I <br /> i I, the prope�ty owner, request to have ihe City o(Everett Backwater Prevenlion Device rebale check <br /> ' for lhe instaliation of the device at the above referenced property address be made payable to, and <br /> sent to, the vendor specified on Ihe back of Ihis form. By requesting the rebale check be made <br /> payabie to the vendor, I agree lo lhe (ollowing: <br /> 1. I will not receive a rebate check directly from the Cily of Everett. <br /> 2. Assigning payment of the rebale lo�he vondor does nol exempt me from f3ackwater <br /> Prevenlion Device Rebate Program requirements. <br /> ----------------- --- <br /> i <br /> I eulhorize the release of my rebate to the vencJor Ilstetl on the back of this(orm pending � <br /> approval of the completed Backwater Prevention Device rebale packet by the City of Everett � <br /> � <br /> � a oG /5 � <br /> � <br /> 'yaa e of Property Owner Date <br /> ---- I <br /> I <br /> � � <br />