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� <br />ack����r l�r�� ��i�� ����� � ��� Pr�gr�r� <br />�f r �t t� �° <br />Project hiumber: (Ciiy to Provide) <br />Please �or�p��ie bo�h sid�s �f �he f4rm <br />F'roper�� t?�ner �ec#ion: <br />Praperfiy C�wn�r �lame: '���'����%�_��° ;'""C . �`�'���� E <br />Installation Address: �' � �' ` "'� ��`�'��-��'� �`�, �.� �� ��'°�`�� <br />��—. . . <br />City: � `� t`�.���'°-� State: �s�' �'� �`p; �' �; ��,�;� r <br />Mailinc� Adc�r�ss (iftli�ferent): ��''`���s <br />� <br />���� City: : �� �°''''� �' ��" S�af�:�� � � ,�r'�- Zi�'; � f �� �� <br />ECtlr3li. �✓ `°'� �x d r s �; ��j � � �"�."�.t�1 w�"a � � �. �,'�" � �i0I1�': ��i ti"� �"'� `,�°r� "��.r�° � .� <br />Tofai Gost to Instafl Device (from cor�tractor invoiee): $ � <br />I, the property owner, request to havethe City of Everett Backwater Pr�vention Device rebate check <br />for the inst�llation of the device at th� aboue referenced proper#y addr�ss be made payable to, and <br />sent io, the v�ndor specified on th���ack�of this f�rm�. By r�questing tFre: r�bate �check be made <br />payabie ta��fhe vendor, I agree ta the��foilciwing: �� <br />1. [ v✓ill not receive a rebafe check �directly from the City af �verett. <br />2, Assigning payment of ths rebat� �a the vendor does not exempt me from Backwater �� <br />Pr�venkion Device Rebate Program requirements. <br />I�uthc�r»� the release of my reba�e to �he vene�or fisfied on t�� ba�k of th�� fQrrrr pend�ng �� <br />apprc�v�� r�f tf�e cc�mpl�ted ��c€�w�ter Pre�rention f��vic� r�b��� a�k�:k b th� Git �f Ev�r�tt <br />i� Y , Y <br />��;�-� �`� ,.�_—�,�� <br />�,��,,,-` � � � <br />/'� � <br />- �,� ..--`'1� �Y f � � � <br />� .. -"` �w` � �' � <br />�ignature of Property t�wner Date <br />