Laserfiche WebLink
! <br /> � <br /> � <br /> � <br /> Ba�c4�water Rrevention Device Re�ate Program <br /> l0en+dar P�yment Op�ion Form <br /> i <br /> � <br /> Project Number: (City to Provide) � <br /> � <br /> � <br /> � <br /> Pfe�se comple�e both sides t�f fihe form r <br /> Prope�ty Owrner Sec�icsn: <br /> Praperty Owner Name: � �� �� ���`���'`� <br /> tnstatlation Address: ���.�� �--�� ���'� ����'�N ��`� �� �'� � <br /> City: �� ��-_ 5t�te: Zip: �� �.� � � <br /> �. <br /> i. <br /> Mailing Addr�s�{�f differ�nf): � <br /> Gity: �tate: Zip: <br /> Email. Phone: ( ) <br /> ��� � <br /> total Cost to Install Device(from contractorinvoice):$ ��P �-�--"�`� � <br /> I,the property owner, request to have the City of Everett Backwate�Prevention Device rebate check ;` <br /> for the installation of the device at the above referenced property address be made payable to, and ; <br /> sent to,the vendor specified on the back of this form. 8y requesting the rebate check be made = <br /> payable to#he vendor, I agree to the followfng: � <br /> 1. t wiN nat receive a rebate check direc�y from the City af Everett. <br /> 2. Assigning payment of the rebat�to the vendar does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release a#my reba#e to the vendor lisfed on the back of this form pending <br /> approval of the completed 8ackvu'ater Prevention Device rebate packet by the�ity of Everett <br /> �,�.�..��.w....�... <br /> ���, � � <br /> � �,_� �_ '�.�.:�`� i <br /> �, . <br /> , � <br /> Signature of Property Owner Date <br /> � <br />