Laserfiche WebLink
Backwater Prevention Devir,e Rebate Prog�am <br />Ev Vendor Payr�ent O�tion Form <br />Project Number: _ (Ciry ro Provide) <br />Please completE both sides of the form <br />� _> <br />Property Owner Section: <br />�--. . — �1.�— <br />Property Owner Name: �,/j ��L(/r/.f 1 ( / �/ ���c-1 .> > <br />Installatio ddress: oCo��Z l0 � ��. ---- <br />City: C//y%�Q t-` Stale:. C�'�� Zip: ���� l <br />A4ailiny�ddress (if dif(erenf): �� � � � �� • — <br />� 9�,2 7S� <br />c��y� i�?l.�f�� �% p� State: �._ Zip: <br />Finall: �C� �'!SS �J��,t�//1 LV{'YI�l�II.'�r�none:( ) �Z�J -z3q-�(� <br />Total Cost to Install Devico (/rom contractorinvolce): $��,���— <br />I, the property owner, requesl to have the Cily of Everelt Backwaler Prevenlion Device rebale check <br />for the Installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on Ihe back of this (orm. By requesting ihe rebato check be made <br />payable to the vendor, I agree to the following: <br />1. I wlll �ot recoive a rebate check dlrecUy from lhe City of Everett. <br />2. Asslgning payment of tho rebale to �ho vendor doas not exempt me from Backwator <br />Prevention Device Rebate Program requiromenls. <br />i----� <br />e-the release� f my rebate to the vendor Ilsted on tho back of thls form pending <br />of the comql6led Backwater Prevention Device rebate packot by lho City of Everelt <br />of P,rope�lY Owner <br />(� �( ��� <br />Date <br />I': <br />