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1 <br /> Contractor �ection: <br /> Sev�e�-- �"v� ��e.n�'. L-�-c �' c�_o 2. q 3� 7�o <br /> Vendor Name!Business Name/UBI umber <br /> SewL,� l �.. �11 l� vti-, S <br /> State of 4Vashington ConUacbr License iJumber. <br /> �(-> �X �-4-I� L��'��tiv�oC lN �� O ll�o <br /> Vendor lviailing Address City Sta`,e Zip <br /> i ��9 �{'G�� I`�' / 0 �V,Ii�.0`i�.WE'Y-t-Y"IC'1'ILI�I/�—�—��Y77 <br /> Phone Email <br /> i <br /> ', the Vendor, agree tu reaelve lhe Backwater Prevention Devics rebafe check direcUy for the <br /> i^stal!ation at the above referenced p�operty addross. By ag�eefng to receive the rebate check <br /> il�ec(ty, I agree to fhe folloeiing: <br /> i. The Backwater Prever�tlon Device rebate amount�vlll be deducted from the fnal Invoice <br /> giv�n lo the properfy ownor ior the Installalion at the properry address roferenced above, If <br /> U�e fot�l cost of Ihe inslallalior is greater than the rebate. <br /> 2 I, Ihe Vendor, am a Washington S(ata licansecl cornractor. <br /> 3 Th� Ciry ai Everott will send a Federal Form 109�J A41SC ta me,the Vendor, for F3ackwrder <br /> Provenlipn Device rebate payments totaling more than $60D per calendar year, and�vili <br /> n�port the same payments to the Inlernal Revenue Service. <br /> r- - -- <br /> _--- <br /> �' I accep�.tho paymenl of the (iar,kwnter Prevention Device rebate from the Clty of Everett p�nding <br /> approval o(the completed packivaler Prevenlion De�dce rebate package by the City of Fvorr.tt <br /> � <br /> ✓���'�� ' `, . -t",�C,�C>.� --- <br /> Signatura of Contrac'or Dete <br /> � <br /> �- ----- - -- _ _— ---------- -------� <br />