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_.. <br /> adkater Prevention Devltce # eba#e Prograiim <br /> Vendor IPayment 00On dorm <br /> i <br /> Protect Number Phy to.Provrd) <br /> 'tease corriplete bQtb stile of the form i <br /> Property )wner Sec4n ��,.,.sL. -LmL <br /> Lrr9 <br /> rr <br /> Property Owner Name: ,vtf^ Cti <br /> Installation Address: ;?, c vti3� <br /> City: vt - State:r 1L Zip. 1 c f <br /> Mailing At4dresS>if different); <br /> i <br /> Cjty;, State Zip:' I <br /> Ismail, Pah�one. ( ) <br /> Total Cost to install Device (from con tractorinvo�ce) $ O( -� ? <br /> I,the property owner, request to have the City of Everett Backwater.Prevenkian Qevice rebate check `° <br /> for tf'ie installation of the device atthe above referenced`property;address be made payable to,:and <br /> sent to,the vendor specified on the back of this form. By requesting the rebate check be made <br /> payobte to the vendor, I agree to thefiollovving: 5 <br /> 1. I wili not receive a rehate check directly from the City of Everett. <br /> 3 <br /> 2. Assigning payment'of the,rebate to the vendor does not exempt melBackwater ry <br /> Prevention bevice R bate,Pmgram requirementsi i <br /> . <br /> . , <br /> I authorize the release of my rebate to the vendor Iisted on the back of this farm pending I <br /> approval of the compteted Backwater Preventio.n.Device robate packet by the City of Everett <br /> j— 6 ) — z1� <br /> Slgnature of Property Own_e Date <br /> ......... <br />