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� �� � rnt��t�� ���������� ����� �� � ��� t�e �`rc��r�n������ <br />���c�car ���r��t�� �ptiort F�r� <br />�� Proj�ct �t�mber;� �(Gi�y t� Pr'r�vide) ���� <br />F'leas� c�ampl�t� �oih sid+�s of the ��rm <br />Property Owner S�ctian: <br />Property �wner Name: � ( �,�;: j �-'� ��I _ ) � `y� C3� �"�� �`�� <br />Installation Addres�: � ��� �'iC�� i �����' E�� <br />t^it�,� .;C':`vstwS�����i�'! �� ^-,tata•s� ��.� � 7irt` �i°*� ��i"'�C��t[���: � <br />-r � <br />Mailir <br />Address (if differenf): <br />State: <br />Ernail: ���� ,���i ;���"`�i.... �,.��� Phon�: (���} -°i��� `�� {��c.�_ <br />Total Cost fo lnsfall Device (fron� confractor��invoice): $ -, � w-���.��� <br />1, the property owner, request to �have the Gity of Ev�retf Backwater Preventian Device���ret7ate check <br />for the installation af the device at the above referenced property address be made payable to, a�d <br />sent��o, the vendor specified on the back of this form. By requesting the xebate check be made <br />payaf�le #c� the vendor, i agree ko th� following; <br />�1. 1 will nat r�ceive a rebate check directly from th� Cify of Everett: ����� � <br />2. Assigninc� payment of the rebate to the vendor does not exempt me fram Backwat�r <br />Preveniion Device Rebate Proqram requirements <br />I authorize fhe �efea�e af my rebate tt� the'vendor fisted on the back of this fQrm p�ndin� <br />��ppr�val of th� cc�rr�pleted Backtivater Pre�er��ion �evice rebate �ac�Ce� by #h� �ity of Everett <br />� � � Y� � <br />�,,, , -� / <br />`,�`�� ',�'''�� .� : r-~_ l,�- -.a �. �"�-. ..,�-� G' � j �' � �� � �i <br />Signature of Property Owner D�te <br />