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I <br /> �oat�rctor dection: � <br /> I <br /> M�,�,,, ,'Iti,� h,�, G o � �-��i ��r, _ , <br /> Vendor Name 1 Business Nai e I UBI Num6er � <br /> Nloen PP� �5�� � i� — <br /> State of Washington Contractor License Number: <br /> I 7S 15 �(( `�- 5f Sr S;�lo�u��� S�, 1✓/F =rS7-`9 U . <br /> Vendor Mailing Address City Stale Zip <br /> '-I �. S 7l; o s�L.c; �i r�,-� �� r., ur.,� �l�„-,l,,t�y c o,�, <br /> — —,-- 7 <br /> Phone Email <br /> I, tiie Vendor, agree to receive the Back�vater Preventlon Device rebate chack directiy for the <br /> instailation at the above referenced property address. By aareeing to receive the rebate check <br /> directly, I agree to the following: <br /> 1. The f3acln�aaler Prevention Devire rebate amount�viil be deductetl from tite final invoice <br /> given lo Ihe properly owner for ihe installalion at lhe property address referenced abovo, if <br /> the total cost of the installatlon Is greater Ihan lho rehate. <br /> ?_. I, Ihe Vendor,am a Washinglon Slate licensed conlraclor. <br /> 3. The City of Everetl vdill send a Federal Form 10991U�ISC to me, the Vendor, for Back�r�ater I <br /> Prevenlion Device rebate payr:u:nts rotaling more than.�u600 per caiend-ar year, and wiil ! <br /> reporl the same paymenls to thF�lrlemal Revenue Service. � <br /> I accepl the paYment of lhe Bacie���aler Prevenlion Device robate from the City oF Everet[pending <br /> ;ipprovnl o(the compleled Backweter Provcntlon Dovico r�bole packagr by Ihe Cily of Everett <br /> �J i <br /> �'�✓"l y,�J�"vc./— -- — �j "�� � ) <br /> Signaturc o(Conlraclur Date <br /> L�------ -- --- — - <br /> � <br /> � <br /> � <br />