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�� �; •� '�. . •� �' �� � ��. � � r' � . t R '/� ' � .:� r <br />�� � :# ' 'i i <br />*7�! y �' � � .. <br />`� <br />'•- •- •'• <br />Please complefe both sides of fihe form <br />Prope�ty �wner Section: <br />Praperty Owner Name <br />� <br />Instalfation Address: _� �.���. ��� �+'°- � <br />City. �� State: �� Zip: ��� � � <br />Mailing Address (if different): <br />City: { _ ..._.�tate.�_---- ZiP: <br />Email: �t A�' ���' '��i ���i ��'t.��i �:�' � !'��''. � �.,a.. Phone: ���C � � � �='�'�-� <br />? � <br />Tatal Cost to Install Device (from contractor invoice)= $ t� �� �� �� � <br />I, ihe proper�y owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device af the above referenced property address be made payable to, and <br />sent to, fhe vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor, 1 agree to the following: <br />1. I wiil not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Preventian Device Rebate Program requirements. <br />1 authorize the release af my rebate to the vendor Iisted on the back of this form pending <br />appraval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />� <br />. S gnatu of Property Owner <br />Date <br />