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; � <br /> , <br /> 1, <br /> �acku�at�� r��+�n�ic�n ��i�e R�ba�� �'rog��� <br /> � 1ie�d�r a� er�� �a�i�n Fc�rm <br /> �Pr��ect I�tumb�r> (Cify to Prvuide)� � <br /> �I�ase eomplete beath �ides af#he`form <br /> P�op�rty Cawner Section: <br /> � � �� � � C�t� �� <br /> F�roperty Owner Name: �h <br /> �.-ZC�� l �� 5��� `� � <br /> fnstall�tion Address� ,- � <br /> ���ity: �'�`�..�'�.'� State: Zip: � �� � <br /> °�Mailing Adc3r�ss{if diff�r�r�t}� ��'� �� <br /> City: State; Zip: <br /> �mai1: ��tu�"f i��� ��t`.'t�1 � ��,,,��`1 Phane: (�(���C�� �� <br /> Total Cost to Install Device (from contractor invoic�,}: $ __�`u1��.�m�� � <br /> I, the property awner, request to have#he City of�verett Backwater prevention Device rebate check � <br /> for khe installatiQn of the device at the above refer�nced prope�ty address be made payabie to, and <br /> sent to,the vendor;specified an the back c�f this farm. Qy requesting the rebate check be made � <br /> payable to the vendar; i agree to the following: ' ° <br /> � <br /> 1. I will not receive a rebate check dir�ctly from the City of Ever�tt. <br /> � <br /> ' 2. Assigning payment of the`rebate to`4he v�ndcrr does not'exempt me frc�m Backwater � <br /> �r�v�ntior� Device Rebate Prograr� requirem�nt�. <br /> 1�uth�ri�e�the releass of my rebat�to tt�e v�ntlot listed�an tt�e ba�k�of this frsrm pending� <br /> ' app�Qval crf the cornp[eted 8ackwa#er Pre�enfion f�evi�e rebat�p�cket by the Cifiy of Everet� <br /> �. <br /> ) � <br /> . ,/�, > l � <br /> Signature o�t�rop�rty�wner ��#� � <br /> ; <br /> � <br /> � <br /> E <br />