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Contractor Section: <br /> SL'\'�l�:Y' 1�''�� '�I�� L� L � l,1 � � � �� �0 �J �. <br /> I Venoor Name i Business N2ms/UB!Nur-ioer <br /> I � <br /> I Se�Ne�- � � �1 l�z v�-� S <br /> � State o° Washinoion Con;racbr License Number. <br /> i � <br /> � ��-� �x �-i5 � nn� w� �8'��aco <br /> I Ver,dor i�•1ai!ing Addr_ss �City Slate Zip <br /> ` �Dlo ��10 -1�7 �____�l,�i����,wer-�ri�nc��V'� ; <br /> i Phone Email <br /> � <br /> I ihe V2ndor, agree to receive ete Bac�vater Prevent�r,n O��r.c= rebat= chzck dirzctly ior tha <br /> installztion ai ihe above reter�nce� �fOP�fi)'2dOf?55 8% B�t�Ei�J ;0 f2C'IVc' I�'� �ebsie c112:,-: <br /> drt�c�ty. I aqra� to tha icllowino <br /> 1. The Backwater Preveniion D�v�ce reoa?e amcunt c�dl te ae�ucted �rem ine ;Iral invei�e <br /> given;o the ptoper,y oemer rcr the i�s:allstien �:;te croper,y acd-�s; r�:�renced abe:e. �` <br /> ine to;al cost of tne in�tallatron is great<r tn�n !he r�bac�. <br /> 2 I ;ne Vendor, am a Washinoton Siaie licensetl contrac:o <br /> 3 Tne City of Evarelt n�ill send a Federa! Form 1059 tv11SC ;c r,e �re ��encur, {or Bac;;ra�er <br /> Prevention Device rebate paymenls,o,aling more Ihan SoGD per calendar year. and�•:i!� <br /> rcport the same paymerds b the Imarnal Revenu2 Service. <br /> j— ----. <br /> � I acc=r� ihe payment of the f3ackwater Pre���ntion Devic= rebate irom tne Ciiy o�Evere�t pendma <br /> iapproval oi Ihe corrol�iad Back!vater Prevenlio� �=vice reba?e package oy the City oi Ever=it � <br /> I <br /> � <br /> � <br /> �!�-�.�, �-���� <br /> � Signatur� of Conl�ac?or Daie ! - <br /> � -- -- -! <br /> , <br />