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���r r�� � �� e � �� r r <br />�� t��r ��� ��c� r�n <br />Proj�cfNumber: � (Gityt�;Providej <br />Plea�� �ompl��� both sid�� c�f th� fc�rrn <br />Prc,p�rty �iwner �ection: <br />Pra�erty Owner �lam�e: ����.�`��,.- ��i�, ' �'�",'��-�-�r�� ���t;��,��-�`�� � ��������� ���r <br />-, <br />Installation Address: � � I,�.) � ���-�����:�' �� ,1�����-' <br />� � � , _. �,.. � �_�- � � � i`�;4,, ; � � a <br />Cii)iill.;< , <br />Total Cost to Instail Device <br />�t�te: <br />Zip:_ <br />t����/+�"� ��� �,���r�,��=����� <br />' State: �..�� Zip: �' ��' �.�� � <br />F�hone: �� �.���� � ���.� <br />, t�;'�," <br />� coniractorinvoice): $ �,�"����--°�'` <br />r� t <br />I <br />I, the praperty owner, request to have the City of Everet# Backwater Preventian Device rebate chack <br />for the insfallation of the device at fh� above referenced property address be made payable to, and <br />sent to, the vendor specified on the back af this form. By requesting th� rebate chec� be made <br />pay�ble to the vando�, I 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 th� vendor does not exempt me from Backwater <br />PreventiQn [�evice Rebate Program req�.iirements. <br />1 a��thorize the release of my reb�ie to the v�ndor lisfied �n the k�ack c�f this form pending <br />a�prc?val of the completeci ��ckwater �reventi�n Devi�� r�bate pack�t,by tf�e Ci�y of���Everett <br />� � <br />I � <br />° �f '�� � '� � �...�. -� <br />� ��.'%�-- ��� � � � � � <br />t. ,--�i' � ,�!>�.-,...��-' � L � " � �_�.� <br />;� C �' i� ,,..� <br />, <br />;; �..�% <br />5ignature af Prc�perty Owner ' Date <br />