Laserfiche WebLink
i <br /> � <br /> i <br /> Backwater Prevention Device Rehate ./�rogram � <br /> „ Vendar Payment Option �orrn � <br /> Project Number: (City to Provide) � <br /> i <br /> Please compiete both sides of the form ` <br /> � <br /> I <br /> Property Owner Section: � <br /> i <br /> Property O�vner Name: ^ �C y l,��J1 Y��`l � <br /> Installation Address: 1 "l U�i� I�!>L1UL�11P r t'C�1 � � <br /> Ciry: �/ � State: �_ /�L�Zip: CI 0 7—V 1 1 <br /> t <br /> Mailing nddress(il dille�en()_ � <br /> City: _ State: Zip: � <br /> � <br /> Email: ei���v����r� �iGV1Gti. Cc✓1'�� Phone: (ybg)�\V- 2Za5 � <br /> Total Cost lo Install Device(6om confracfor invoice): 5 j I � � �. � � � <br /> � <br /> � <br /> I, the property owner, re�uest to have the City of Everett Backwater Prevention Oevice rebate check � <br /> for the inslallation of the�ievice at the above reterenced property address be mac�e payable to, and <br /> sent to,the vendor specified on the back ot this form. By requesting ihe rebate check be made � <br /> payable to the vendor, i agree to the follo�ving: <br /> t <br /> 1. I will not receive a rebate check duecUy from the City of Evetett � <br /> 2. Assigning payrnent ot the rebate to the vendor does not exempt me irom Backwater ( <br /> Prevention De:vice Rebate Program requirements. i <br /> — � <br /> I authorize Ihe reiease of my rebate to the vendor listed on the back of this form pending � <br /> approval oi lhe completad Backwater Prevention Device rebate packet hy the City of Evereri <br /> � <br /> � <br /> i <br /> , � <br /> � �. � 5/�s/is i <br /> Signature of Property Owr� Date � <br /> E <br /> � <br /> � <br /> ( <br /> i <br /> , <br /> ! <br /> � <br /> � <br />