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� <br /> � <br /> I <br /> Contractor Section: <br /> ,9Po�Lc� ��r,rr�1��%�j - _���, 3 0�3 asJ _ <br /> Vendor Name i Business Name ; UBI Nwnber � <br /> /�t�%GL ��G�3G1_ ------- --------- --- <br /> Slate of lNashinylon Contractor License Number � <br /> 5�ieJ ?i�" �/"c� �v L /�'l.%r�'%s✓�%��% w 9� ��/��-% <br /> V�ndr�r �vlaihn�,� Address Gity State lip <br /> _jd7 � /Sc� _ _ _. I <br /> Phone Emaii <br /> I, �he VCndor aqr¢e to recewc ihr. Eiar,kvdatr.r Preventinn Dewce re�a�e r.heck tluectly (or the <br /> installatmn �t 'he above referenced property aA�ress Ry agrecing to rer.eive the rebate r.heck <br /> directly, I agree to Ihe followmq <br /> 1 The F3ackv�ater Prevenlion pevire rebate amoun� will Ge deduc�ed from the hnal invoice <br /> givr.n to the prnperty nvmer fnr the mstallahnn at thr, prnpnrty ndAre55 re �renceA ,�hovr, d <br /> the totr�l cosl of�hc inslnllation is gmatF�r Ihan the reh�te <br /> i <br /> Z I, Ihe VenJor, ain a �Vashinylon State hcensed conlractor ' <br /> 3 Thc Cdy ul Everetl vnll send a FedurafForm 1099 �v115G to rne. �he Vendo�, (or Bach�vatei <br /> �'revention Dewcc rebale paymcnt5 tutatuig rnore Ihan $Ei00 per calendar ye�r, and�vdl � <br /> ���purt die sarne payments to the Internal.Revenue Sernce � <br /> I <br /> -_ — � <br /> I ar.cept th�p.iyrnent nl thr Hack�valPr PrevenUon f)ewcP rrh.ale from R�a f:dy ol Evnrnit pendmg <br /> appmval ol th� com�IrtcA Hir.kwater Prr,venlinn [lnvir� rrha�e par.kagr hy !he Qly �f fvNrntl <br /> � <br /> � ___-- � <br /> 'µ• - -- - _ __ ___ __ _ _— .3 /�j/is I <br /> S�ynaWrr, of Contrac�or Date <br /> I <br />