Laserfiche WebLink
AA�16mniiQigxt i€7t �&AIadF�'�-92kF�tUY7a9"f�:2-A.tdR€Sii29,304#8 <br />� ��c�v�t�r �r�er�n��€�v� ���a9�� ���a�� �rr����rr� <br />���� ��rr ��r�dr�� �'�����a� ��a�a�� �c�rr� <br />� Project P9umber _ (Gity to P��vrde) <br />Pi2as� com�ziet�= 1��t�� �Sd�s of iEae #orm <br />prapesiy C�wner �ection: <br />Propetty CJ'�vner Nama: __�-_Y_'j� j,Y � l.<4'-� <br />Inslallation Addrass: ���'--"`��d�s� ' /�' �� �' ' � � ---- <br />Cit�+: ��3,.— State: �� Zlp:- - 4'`L�� " �-���w--_''}�'_""""'_'_. <br />�h�1ai{ing A�Idress (�Ydi�ferant): <br />City: —_ �take: —_= -- -- Ztp' _ ` <br />Email:. . Phane: ( ) � <br />Totai Cost to instail Qevice {fran cantractorinvotce):. $ � � _q._(L— <br />I,.the pioperty nwner, request to have the CiLy aP Cvereit 8ack•xater Peevention Device rebate� cF�ac:k <br />for the installafion of the devico at the ahove referenc�d property address be mad� payable fo, and <br />�sant lv, Ihavend+�r sper.ifi�d on the back aP tiiis tann..By rec�Uastino th¢ rebnf� checl< l�e made_ . <br />payable lo Nie vandor, l agree to the fnllowing' � � <br />i, 1 wi11 nat recerra a re6ate eheek direct{y feom the C1y oi Everett. <br />2_ AsSignir.g�payment of liie rebate tn lhe vendor does no[ exempl me frum 8ackwa�et . ,� <br />Prevention Device Reba4e Prograrn requirements. � <br />I authurize the�release ot rrry reGafe to the vendor lisl.�d on the back of Nis form pe��ling <br />2pproval o( ihe cornpleted Backvrater Prevention Device rebate packet by the Cily of Everett <br />�^^. sz4i�,��r - <br />j�v <br />F <br />� ir� i t����u� iF't���,k�y� '.fv'�'ler <br />9/28120'16 <br />Dale <br />.........__.___. . . ...... _ . . __._ __. <br />