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I <br /> r -- - - - - -----i <br /> I <br /> I • <br /> j <br /> � <br /> I I <br /> Contractor Section: i <br /> � ( / ------ -- -- ; <br /> � I �2`i� 5.—�'/"C.L.�Vo.,'�- IQ C4 ��1 �_4 �,C72- -ilZ- 1 � 3 � <br /> endor Narne/Business Name I UBI Number i <br /> I <br /> ir9,R �f J 1 �+t�c� �� P�� ; <br /> � Slate ot Washington Contractor Lfcense Number: <br /> i �� � � �✓�y1'Lw �h'tiL= �l/-FlvwT L.?�- R 1'Z-� 8 . � <br /> Vendor Mailing Address Gly Stale Zip � <br /> � <br /> � ��Z� — �'�`l— 0 ��-'> � /�����-.,. l�-t� L L L 'l�f�7(�'('7rrir7+11�C oL�— � <br /> IPhone Email , <br /> � --- - I I <br /> I <br /> � I, �he Vendor, agree lo receive ihe Backviater Prevention Device rebate check directly for ihe I <br /> I installation at the above referenced property address. By ayreeing to receive Ihe rebate check <br /> 1 directiy, I agree to the following <br /> � <br /> � 1. The �ackwater Prevenlion De.vice rebate amount v�ill be deducled from the f�nal invoice � <br /> I given lo ihe praperly owner for the inslallation at the properly address referenced above, if � <br /> I the btal cosl cf the inslallation is greater than Ihe rebate. � <br /> ` 2. I, Ihe Vendo�, am a lNashinglon State licensed coniraclor , <br /> i3. The City o�' ,re�t will send a Pederal Form 1099 I�iISC to me, �he Vendor, for Dackwater , <br /> i Prevention ��evice rebale payments tolaling more than 5600 per calendar year, and will <br /> � report Ihe same payments to the Ir�ternal Revenue Service. <br /> I -�----- - ------------ � <br /> � I accep� lhe paymenl ol�he Backv�ater Prevenlion Device rebate from ihe Cily ol Everelt pending ; <br /> iapproval of�he compiefed E�ackwaler Prevenlion Device rebate package by Uie Ciry of Everett <br /> � <br /> � �� ----- - 3— � �_�5—. <br /> I Signalure of Conlractor Dale � <br /> � <br /> 1 --— _--- <br /> I I <br /> � � <br /> I <br /> ----_._�.- • --._ ..._�. ._ ._ _- -- -- ---_ _._, _.. _. . .._ _ <br /> ` ---- - - - -- - - -- <br />