Laserfiche WebLink
Backwater Prevention Device Rebate Program47.7. <br /> Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: Gj Pe_::-k-e--r-ae_r---i <br /> Installation Address: 2.._\ ir) <br /> City_ W State: L ) Zip: t °3 <br /> Mailing Address(if different): 2_542-S r-1 ci-- 11111 8.6- <br /> City: <br /> &City:'-61/--e-ire State: l_.^-44-- Zip: 9 t.7 2-c r <br /> Email: Phone: ( ) SI 1—_00 C)0 <br /> Total Cost to Install Device (from contractor invoice): $_ g,}-~ 1 <br /> I,the property owner, request to have the City of Everett Backwater 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. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will not receive a rebate check directly from the City of Everett. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my rebate to the vendor listed on the back of this form pending <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> SP/P <br /> e19- 1,6- <br /> Signature of Property Owner Date <br />