624 WETMORE AVE 2018-02-12 - Laserfiche WebLink

i i E 4 1 Backwater Prevention Device Rebate Program 77. Vendor Payment Option Form 1 (City to Provide) i Project Number: t t Please complete both sides of the form 1 Property Owner Section: i E Property Owner Name: 110 at " Installation Address: el r: d Zip: City: ' s- State: r. i Mailing Address (if different): t ate. 3 I City: State: ZEp; Phone: ( ) i Email: i Total Cost to Install Device(from contractor invoice): $ i Iowner, request to have the City of Everett Backwater Prevention Device rebate check for i. , h propertyi the installation of the device at the above referenced property address be made payable to, and sent to,the vendor specified on the back of this form. By requesting the rebate check be made i payable to the vendor, I agree to the following: 1. I will not receive a rebate check directly from the City of Everett. 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater s Prevention Device Rebate Program requirements. II I authorize the release of my rebate to the vendorItesi don the back of this form pending I approval of the completed Backwater Prevention Device rebate packet by the City of Everett is lir"— . Date Signature of Property Owner j j i E Y i i 9 1i