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�� ` ���T �°�9d������9 ��'1�� ����� �`���'� <br />�, � '��r���� ��rrn��� ��i�n ��r� <br />Proj�ct Number: (Grt,y ta Provide} <br />. . s t — • ,e# �- • - `� ' <br />t�r+a�s�� ���aer �����or�:; <br />,_._,—______. . ___`__ � � <br />� ,�`u c,��� � .�,;� � � �� �- <br />Prs��rty C�uvn�r (��m�: �, �t t ' �� °`�.`,� °.�`�,, <br />y � . <br />Instaliation Aridress: ��`°`��•t"" � " �""""� ~ � � f <br />�ity. i" i.�`�„J�-t.� �" �`-- St�te• �,+"%�".. �jp, ��c�-' '� ! <br />M�iiing Addr�ss (if diilerentj. � �i �t °� � �� � � � <br />� � <br />j , <br />. <br />Git�: �t -.,f � �-' � Stat�: �� �` Zi�; � � �� <br />.� <br />� � ����� ��d"�w�'��� � �� � � � <br />�rnail: ��� � f� •:�� P,hon�.���� �.��-' � t 1-: <br />iot�[ �ns# to Insiail D�vice {frr�m contr�ctor invr�icu); �_����� "�� � <br />1, tl�c prope�ty owner, requ�st to hava th�; Gity of Eve�e#t Qackt�v�te� �'re��ention,�7evice rebate ch�ric <br />for fih� inst�IPati+�nAf ihe devica at khe above referenc�d properly �ddcess 8c rnarle payabte tn, and <br />sent to, the vandor spe�ifed on the back r�F this (orr�. E�y r+�questing the rebate cl��ck b� m�de <br />p�yabte t4 tho vc�ndor, l ag�ee ta tfie folipwing: <br />9. I wili not receive a rebate cher.k direclly frvm the Ciky o('Eu�;rett. <br />�. Assigning payment af th� reb�te ka th� vendar does not ex�mpt me fream 8acica��ter <br />Preventian Device R�bai� Program requircments. <br />( aukh�arizs tite rele�s� of my r�l�ate to the:v�nclar tisteci an th�: 6ack n( this fic�Tsn p�nding <br />approval ofi the ca�n�ieteci Eiac;ksvater Pr�ventian B�vic� reb;�i� packe# #�y ttl� City of Everett - <br />��„ �` � <br />,. <br />�� �_��r _ � �� r � <br />s� � <br />�sgn�#ur� sf Pr�aperty C�vuner ���e <br />