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Jul. 16. 2015 1:35Ah1 Snohomish yo. �69� P. 3 � <br /> I <br /> i <br /> I <br /> _ -- —... . _.._ I <br /> . ., .. <br /> _ . -----. . <br /> : . . ' . - .. I <br /> .. i <br /> Backwafer Preventl�ort [9evl�ce Rebate Pro�ram : . ! <br /> '>Vend'or Paym�nt O�atio�n Form � <br /> Pro)ect Num6or. ' (C!(y to RroNde) . , .. . . � <br /> . .. . � • � i <br /> .' � � . , . , : � , � - . � . � . , . . i <br /> Please com,plete both sfdes of the form i <br /> : : `. . ....... . :... ; <br /> , , <br /> . . <br /> � <br /> Property Owner Section: , •. <br /> Fioperty 0wnerNamQ: / /ih �'i�� . � <br /> , i <br /> � �� . � <br /> Inatelletion�ddress: ---- ' <br /> Clty: C(/G $late:_��� -d`�i: ��7�J� . I <br /> �� <br /> MaIIIng�Address:(ffdlfferOnQ:�� z z . 7 ��:---- : <br /> c�tv: rf`/� �, � swto• !r/.�� �iP: 9�L'ZG / ,. , <br /> ,/ ��i ,n� �/�' .�Phone;,�1���--.. <br /> �msll:/� :/� �/L�f� , _ ,� / <br /> Tolal Coel lo Inelall Device ((rom confracfor.lnvolcoji S. 2 �f 3�• 8� � �" + <br /> I, lhe proparty owner,�oquouFlo ttovo Uidblty:ol EveroN BockwdlarPtovonUon Dovloo rubOW chuck <br /> lor tlm Insletlallon ol lhe devlce at lhe above.reterenced Droporty nddros�be made peyeble lo, ond <br /> stint to, iha vendar epecified on lhe tiack of lhfs fortn. 6y roquesling Iho[obato check be made <br /> peye6lo lo Ihe vend�r, I aqree to lhe(oqawing: . <br /> L` I WIII nol t9coW�d f6bale check direclly frdm lfie Clty ot EvaFett. '. ,. <br /> 2, Aealgning paymont o11he febetu lo the vendor does nol exempl me from BeckwNler <br /> P(evenUon Oevlco Keb3te ProgreM raqulremenl9. <br /> I eulhodze 1he relaese of my rebale to the vandor 1151ed on lhe back ot lhls form pending <br /> eppraval ol ihe compleled Backwotnr PrevoNlvn Dovlco retie�a peckel by tno Clty ol Everetl <br /> ����:� _ - _ .�_._.�.s '��r <br /> SiAnaNre�of Proporty Owncr Dato <br /> � <br />