Laserfiche WebLink
� -" � �p M �� x ��. - � � � � � � X. � i- . ` � - .Y <br />��� � i', • <br />r� M # � a <br />s � . �., � � i. �" <br />Ptease complet� bath sid�s of the form <br />Proper�y tJwner Secti�an. <br />Prc�perty Owner Narr <br />In�tallatian Address: <br />'� �ip. � �'Z �' ,�ie <br />Gity: ��� R _ St�te: <br />Nlailing Address {if different): <br />Gity: �tate: Zip: <br />Email: <br />Phonet (�'.� � `�''�°"��`._ - �r•`��� <br />� �� <br />Total Cas# to Install Device {frorn con�ractorinvaice): $ ��� �� "� <br />I, the property owner, request to have the City of Everett Backwatec Prevention Device rebate check <br />for the inskallation of the device at the above referenced proper#y address be made payable to, and <br />sent to, the vendor speeified c�n the back of this farm. By requesting the rebate check be made <br />payable ta the vendar, 1 agtee to the following: <br />1. I will no# receive a rebate check directly from the City of Eve�ett. <br />2_ Assigning payment of the rebate to the vendor daes not exempt m� from Backwater <br />Preven#ion Device l�eba#e Program requirements. <br />I au#harize #he release of my rebat� tc� khe vendar iisted on the back of this form pending <br />approval r�f th.e compl�ted Backwaier PreventiQn Device rebate packet by the City of Everett <br />� <br />1` <br />S,�g�rt ture of~Property Owner <br />�. <br />� �� � � ��i <br />C?ate <br />