Laserfiche WebLink
� <br /> ,, <br /> ; <br /> Backtivater Prevention Device Rebate Program j <br /> Err Vendor Payment Option Form � <br /> 1 <br /> � <br /> Project Numher.__ _(City fo Provide) , <br /> � <br /> � <br /> i <br /> Please complete both sides of the form � <br /> ; <br /> Property Owner Section: ' <br /> , <br /> Property Owner Name: 1 (-< <//+�.'M �/7J-ny _ <br /> Installation Address: � E G( ���5 <br /> City: liEf..� Slate: �n�z;P: 9 n a� � � <br /> Mailing Address(tl different): � Y� � lx•h�;� ,� <br /> /rL^r� ��.�n (7.� � <br /> Ciry: � �lc�vfi State: la/� zip: `^1 � �� S ; <br /> Email:� CG�YiT��I-rf.�1�1 �� Gt�u�s�. C�htf Phone:(`j75) 3YY (�� 3 � <br /> � <br /> � <br /> Total Cost to Instail �evice((rom conbactorinvoice):S 3 ��� � ' <br /> I, the p�perty o�vner, reques[to have Uie City of Everet?Cackwater Prevention Device re6ate check i <br /> for Ihe instailalion oF the device at Ihe above referPr,xd property�ddress he made payable to,end i <br /> sent to,the vendor specified on lhe back of this form. By requestinn ihe rebate check be made <br /> payable to the vendor, I agree to the following: I <br /> 1. I will not recoivo a rebate check direGly from the City of FvereQ. <br /> 2. Assigning paymenl of lhe rebate to Ihe vendor does not exem{.i me from Baclnvater , <br /> Prevention Device Rebale Program requirements. i <br /> i <br /> I authorize lhe release o(my rebate to the vendor listed on the back of this form pending <br /> approval of the complQted Oackwaler Preventic:� Oevico robate packel 6y lhe City oF Everelt , <br /> � <br /> i <br /> _�� - ��.� , <br /> Signature of Property Owner Date ; <br />