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�y �4 y �. - K .r , Yl�.,. � ..� .� ,� Yt ,�, r• :� _�' �?, �s � � s r; <br />.�. ..�= � _ <br />�° �4 '� �' ;.t � � � *' <br />i����� <br />� � . - �:.. �• ' • I ` <br />r k �, �- • a r- s `+ <br />I" rkr, �,, �► <br />Property Owner N�m <br />Installa#ion Acidress: f � �' � � , �` ' � �°° <br />� <br />Gity:�' � %� _ Stat�. ���.� �ip: ��� � <br />Mailing Addrsss (if different): <br />City: State: _ �ip= <br />EmaiL• <br />l�han�::( j�-`�����'���� <br />� �� � <br />TQtal Cc�st to Instal! Device (fram contractor invoice)_ $ r��� ��� ` "`�� <br />1, the property owner, request to have the City af Everett Backwater F'revention Device rebate check <br />for the installafiian di the d�vic� at the above referenced property ac��lress be made payable to, and <br />sent ta, the ven�lcar speci�ied an ihe back af this fc�rm. Sy requ�s�ing th� rebaie ch�:ck be made <br />payable ta the vendor, i agree to the t`ollowing: <br />I will nat receive a rebate check directly from the City of Everett. <br />2. Assigning paymen� of the rebate #o the vendor does not exempt me trom Backwater <br />Prevention Device Rebate �'rogram requirements. <br />i authoriz� ih� release of my r�bate ta the vendar #isted on the back of this f�rm p�:nding <br />apprav�l c�f the cc�mpleted Bac�Cwaier Prevenfion Device re�aat� packet by the .�ity of Everett <br />� <br />� .� <br />Sign��ure of Praperty Qwner <br />�� � �� <br />Date <br />