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� ��� � ♦ . y. .,. � �.� q .. �. .... � � � � � . # � .� �_ <br />��.f :� .. ! � �� . �i � <br />� <br />Projecfi Nu►nber: ��� '� � � � :(City to Provide) <br />Please complefie both sides of the form <br />Property Owner Sec#ion: <br />Property �wner Name: � � t�1� �.. L� fi ►! � �`"��� v+. �`� � �, �'"� �t- <br />Instaffation Address: �(� j'� :�- � �i ��� � � <br />Citiy: �" Gf ��� �.- �`"�' State; E.� ,�- Zip; <br />Mailing Address (if dr'f�e�eni�): � <br />City: �'. � � r,� �"1'� � <br />Email: Phone: ( ) <br />Total Cost to Ins#all Device (�rorn coniracior invoice): ��'�� �� <br />J, #he property owner, request io have the City of Everett Backwater Prevention Device rebate eheck <br />for the installation ofthe device at the above refereneed property address be rriade p�yable to, and <br />sent to, the vendor speci�ed on the back af this form. By requesting the rebafe check be made <br />payabfe to the vendor, I agree ko #he follawing: <br />9. I wili not receive a rebate check direckly from the City of Everett. <br />2. Assigning payment af the rebate to the vendor does not exempt me from Backwater <br />Prevenfiian Device Rebat� Program requirements. <br />i authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval �f the completed Ba�ckwater PreventiQn t�ev�ce reb�te packet by the City oP Euerett <br />����` � � �° <br />Signakure of Praperky Owner <br />� � � � ��3 <br />�ate <br />