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! <br /> + <br /> ; <br /> ���F;�a��a� f're��r��'sor� �Ae�i�e Reisa�� IProaraare ' <br /> �'�ncie�� Pay��n� Op±i�n �orrr� � <br /> Projecl Number. (City to Provide) •� <br /> i <br /> � <br /> I <br /> F'Ee�s� c�ur�pte4� l�o4h sBde� of clae ffoPax► � <br /> i <br /> , <br /> �rQq�ee�y Ov�ng�' ��ction: <br /> � <br /> � <br /> Property Owner Name: l/ � l.,�ur��=-�"� <br /> InstallationAddress:�u �� �� y� ' <br /> City: �A2`T State: .� Zip: (U v�� 1 <br /> Mailing Address(iI different): �'79"T'1�P — � <br /> i <br /> City: State: ZiP <br /> � ! ` � I <br /> Email:' ' Phone: ( ) ; <br /> Total Cost to Instatl Device(Irom controclorinvoice): $ l'���� /� `-� <br /> — i <br /> I, the property owner, request to have the City of Everett Backuvater Prevention Device rebate check <br /> for the installation of lhe device at the above referenced property address he made payable to, and <br /> sent to, lhe vendor speci(ied 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 direcPly from the City of Everett. ' <br /> i <br /> 2 Assigning paymenl oP the rebate to the vendor does not excmpt me irom Backwaler i <br /> Prevenfion Device Rebale Program requirements. <br /> --. ----- -- ---- <br /> -- � <br /> i — <br /> I aulhorize the release of my rebate to lhe vendor listed on fhe back of Ihis torm pending � <br /> approval of the compleled Backwater Prevenlion Device rebale packet hy the Cily of Everett <br /> � <br /> -�'�-_- <br /> �� � �� 1 <br /> Signalure of Property Owner Date <br />