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i <br /> � <br /> � <br /> Contractor Section: , <br /> --- --- --- _----- -- - -- -- --- _ . .—.. _ _ 1 ; <br /> I ��y� -- — -- , � <br /> -._ uLL�_ _I�GI�MI,i�Nrr L�.?—v1_j - cisSl � <br /> i <br /> Vendor Name I Dusiness Name /UBI Number ; <br /> /�r��c_ ''�L SC',.�c�.� _ _------ - ------ - � ------ <br /> S'3te of Washington Contractor license Number <br /> . i�' <br /> I S.=L7.. 7L-�v� ..�/i �?��ZY.��l�L4%. . . W2--- ���L��- <br /> Vendor h4ailinq AddrP,s Cpy State Zp � <br /> ; � <br /> I L�i�s � z ���-� --- -- ----- ---- I <br /> Phono ' Email I <br /> I ' <br /> - -- -- - ' <br /> _ - --- - — -—.._.. ---_ -----� <br /> I, the Vendor, ngre^to receive lne Backwater Prevenlion Device rebate cher.k dlrectly fnr lhe � <br /> instnu�lion at (he abnve reterenceJ properly eddress. E3y agreeing to iecelve the rebate check <br /> dlmclry, I agree to the follo�vinu: <br /> 1 Thr. Bar.kwater Preven;ion Device rebato amount will be deducfed frum lhe final invoics � <br /> given to Ihe property ovmer for;he ins!allation at U�e property�+ddress roferenr,ed ahovq li <br /> Ihe total cosl of lhe inslall�lion is yreater than the rebale. <br /> ) I,th� Vendor, am a Wa;hinglon Stato licensed conlrador. <br /> 3 Thr Cily of Cverell will send a Federal Forrn 1799 A415C lo me, llie Vendor, for Backwalar � <br /> Preven6un Ucvice rebale payment;totaiing moro than SG00 per calendar year,and will <br /> report the seame paymen!s tn �he In;r.rnal Revenuu Servlr,e <br /> �-- .. .--_ ... ... . . .�_.�_" '_____. _..-_-_ ' <br /> I axept the payment cf lhe[3ack�vater Preventlon Device rebale from tlie City of Evcrell pending ! <br /> I .ipproval of ih�compleled Dackwater Prevenlion Oevir.e rebate parkage by Iho Cily of Everetf � <br /> _ — I . <br /> - ---- - -- - �-r-�-�-- , <br /> Signalum of Coniraclor `��._ Dalo <br /> __ _ — --- - . __ I I <br /> � <br />