Laserfiche WebLink
� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Numbec (City to Provide) <br />Please compiete �aoth sides of the form <br />Property Owner Section: <br />Property Owner Name: � a.r�aA f�a �e�c e; �� __ _ <br />Installation Address r�OQ(n ����i � n � n aU Pi _ <br />City: ��� G('L't"1 State: �� Zip: �'lc��10 I__ <br />Mailing Address (if dilferenQ: I� 3 D L aS�' D2 _�r ___ <br />City: N� � I I G-E e iC Stale: �_ .__ ZiP: C�a � l _ <br />Email: �e?.Qell bG � o�{' G� . Cora _ Phone: (�iZ� 3�0.- 7�cS- `j <br />Total Cost to Install'Device (Imm confrar,ror invoicef $ <br />I, the property owner, requesl lo have lhe Cdy of Everell Backwater Prevention Device rebale check <br />for I��a irstallalion of Ihe device at lht above referenced property address Ca made payable to, an� <br />senl �o, lhe vendor specified on the ba�k o( this torm. By requesting [he rebate check be made <br />payaolc to Ihc vendor, I a�ree lo the following: <br />1 1 will nol receive a rebale check diredly from Ihe City of Evere�t <br />2 Assic�ning paymenl of Ihe rebate fo the vendor does not exemp� me irom Backti;3ter <br />PreveMion Devlce Rebale Program requiremenis. <br />I anthorize lhr, rr,leasr, of my rebale to lhe vendor Iisted on the back of this (nrm prndinp <br />approval of the completed Backwaler Prevention Device rebate packet by Ihe City of Everelt <br />��'"�•�.Y �. � .S—.� � —?� � J <br />Signalur� 01 Property Owncr <br />Date <br />