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� � � r � �i �i� t r r <br />�� �r�de�r ��� �r�� pti�n F�r�n <br />Pr�jsct Nutnber: , (Cfty fc� Provide) <br />ple�se �ar�p4��� both si�le� a# th� f�rm <br />^° �i �.x v tir: ; �,� , , ,� <br />�. __�� __ � _ _._ _�...... � <br />Prop�rty tJv�ner N�me:.���� M�'�.� ��� �.� �l �4�J�� �._..µ_.�.. <br />- �. <br />lnst�fiatic�n Addr�ss: _ ���..�� ��� ��� ;�. . <br />City. ��� �� 1� ��r`� � State: ��,i *�� �i#�; <br />IUf�iling Address �'rfdiff�r�r�t): �-�-�� � ��° ���"� }j�' � . <br />� � � , � ��'��� � <br />c�ty � ��' � i'�����` �� "t� � st�t�: ��`.� �ip< <br />Email: `:���.,� ��� r`��'`�...�.�:�..�:��:.�� � �"� F�t�one. ��� ���:� #.�� `<_�<_,� ��-�"�. <br />� <br />Total Gost to ins#�li a+�u'tce (from cc�nfractarir�voice): $ _.�� `�� <br />I, th� prcrp�rty o+rrner, re�u�st #� h�ve the Gity of �v�rett E��c3cwater Pr�ventinn Device rebate cF��cl� <br />for 4h� ins�llatic�ri c�f th� device at the �a4�ove refer�ncecl property a�dre�s be made payab6e to, and <br />sent ta, #h� vendpr s�ascified on the back c�f ti�is form. By re�questing th� re6at� check be made <br />pay�ble to the vendor, i�gr�e ko #h� foflovuing: <br />9. I wifl not rec�ive a rebate ch�ck clirectly fram #he Cily t�� Everett: <br />2. Assigr�in� paymenf of the rebafie tra the vend�r d4e� not ex�mpf m� from �ackwater <br />Rreveniicrn Deuice Re�afi�°Prograrn teq�iirements. <br />I authorize the r�i�ase a4 my rebaf� ta the vendor {�sted on the b�ct� c�f this form pendir�g <br />approv�l of the cort�pleted Backwaier P�evention D�vice rebate p�cket by the City o� Everett <br />�.� � ,� � �.�' � � � <br />���� � <br />Sign�ture r�f Property C?wne� C�ate <br />