Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Vendor Pay�ment Option Form <br />Project Number. (City to ProvideJ <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner fVame� <br />Installalion Address: � -1 U �_j <br />City: ���1`�' State: <br />fvlailing Address (if different): <br />� <br />6� <br />z�p:���-G� <br />City: Siate: Zip: <br />/�J�., . +I ' r <br />cmail: �� � / \ `" �e SC� i� . � ��.c � � ( Q� Phone: (y,ZS) "i� Z.rI S� <br />Tolal Cost to Install Device (from contractor invoiceJ: 5 <br />1, ihe property ormer, request ro have the Cily o( Everett Backwater Prevention Device rebate check <br />for the installation of the device al the above referenced properly address be n•,ade payable lo, and <br />sent ta, tl;e vendor specified on the back c( this form. 6y requesting the rebate check he made <br />payab�e Io the vendor, I 2gree to the follo�ving: <br />1. I will not receive a rebate check directly from the City of Everelt. <br />2. Assigning paymenl of the rebate to the vendor does not exempt me from Rack�vater <br />Preventlon Device Rebate Program requirements. <br />I authorize the release of my rebate to lhe vendor listed on the b <br />approval of the completed Backwaler Prevention Device rebate <br />! <br />/` l��,L > l/����/ �—� <br />Signature of Property Owner <br />ack of this form pending <br />packet by the City of Everett <br />� 2��s <br />Date <br />