Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />ProJect Number: (Cify to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vnEer Mame: <br />InstallationAddress: S�O %D �Yu�l�Avi <br />City: �✓eiC'� State: l.�cc _Zip: <br />Mailing Address (ifdiflerenf): 7 ��_% S�Z��-�Y•i S� ' <br />c U <br />Ciry: S y �!� o i„ i�S G, State: r,ri •°� Z�p:_1� � i <br />Email: Ru ��v .� 3�/�l SN• C_ c� /+^ Prone: ( y.u) �? 7U'� 7 S/C <br />�� <br />Total Cost to Insiall Device (lrom cont�actorinvoice): S�v�3 � <br />-- -.� <br />I, the property owner, request to have the Ciry o( Everett Back�valer Prevention Device rebate check <br />for the installation of the device at the above referenced property address be made payable to, and <br />seN lo, the vendor specified on the 6ack of this form. By requesting lhe rebate ;heck be m2de <br />payable to Qie vendor, I agree to lhe following: <br />t. I���ill not receive a rebate check directly from the City of Everett. <br />2. Assigning payment oi the rebate to the vendor does not exempt me trom Backwater <br />Prevention Device Rebale Prograrn requiremenls. <br />I authorize Ihe release of my rebate lo the vendor listed on Ihe back o( this torm pending <br />approval oi the completed Backwater Prevention Device rebate packet hy the City oi Evereti <br />����L� � <br />Signature of Property Owner <br />Date <br />