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Gontrar,ier :;2c�iei�;
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<br /> ! J�i�/V L I'� T I'� ��:���; :\ 1. �� . � O � �,i -�-ll �U l.�
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<br /> \/endor Name i Business ��ame f Uftl Numher
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<br /> Sta_;e n`Washington Con�rac;or License I�umber
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<br /> ' 'Jendor A4atling P,ddress �� g!M?o ;:p '
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<br /> Pnone cmad
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<br /> , e e c o , ac�re, lo recen e the 6ac<.rater Prevention De ii,.e reoa,e cnec,c diracUy in- 7 _
<br /> �s'allalion at ihe abo��r re(2renr,ed prop?rty adtiress By agr=eing to raceive Ihe rebata r, � : .
<br /> �:��•.� �I:, I agree io the iollowing
<br /> I i nc Backwater Przveniion D�vice iebate amcun! �-+ill te deduc,ed irom ihe fin�l imioic
<br /> ���.•,n m thv prop2rty o�.�ner sor the ins[atlahen at ine ��rcuer�; addre��s rc'��n,n,--,d :! �; „ ,
<br /> �,.�, :o,al cosf of tne inslallation is grea�er tnan the reha�e�
<br /> .. I t� e '✓endor, am a W��shingion St2te hcensed contrano:
<br /> ih: Ciry oi Ev=rett v�iil send a Fedsral Form 109g �41;,_' ;., ,, ;� ,, ,,,er.,fo,. ,,, .... � r
<br /> F�����:=ntion Device rebate payrnenis tela�ing mor2 tiiai, > �. , .; I : ;,r . I
<br /> ; nr1 ihe sarne pa��ments lo the Internal Revenue Sen ,�
<br /> � n-reci ih� p�yment of ihe Barl;a�ater Pr=v-nlien D�vlc= rehne ;rorn U�e C�i; �r Eveie�i Er,:ndni�i I
<br /> ; ;�,proval oi the complefed Ba��e•�ater Pravcntiun De��ice reba!e package by ihe City of Evere;t ,
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<br /> Signature of Conlraclor p�,iF
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