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c:ontractor Section: <br />/7 / i�%�' ii i�j�. /+� Z L ili L* �xJ _> �" C/I �— C/ S i� <br />Vendor Name / Business iJame I UBI Nsmber <br />�rr,��L���_L i — <br />Sta'e of ��4�ashingron Contractor Licers= Numb�r. <br />-s � .7�1=r�v� /vr= MAIZ S/5 il�/�js .1NA _��.'�-' r.J <br />V2ndor I�Aailing Address City Sta!s Zip <br />�"� � ��SJ_-1.�0 7 <br />Pncne ' Email <br />I, the Vendor, agree to rec=l��e tne Backmater Prevention Devic� rebate cneck dire;liy for the <br />insialfation at ihe abov� referenced proper;y address. By agre�ing to receive the rebate check <br />directiy, I agree io the follo�•ring: <br />i The B2ck�vater Prevenlion Device rebate amount �t�ill be ded�cted rrom the final invoice <br />aiven fo fhe property ov.�ner for Ihe ms;allation at the property address referenced above, if <br />�i�e toial cost oi ;he Ins�allation i; nraater than the rebate. <br />=. i, the Verdcr, am a Vdastilncton S'ate i�censed cortracio� <br />The City of Evcrett u�ill send a Feoeral Form 1G99 11ISC to me, the Vendor, icr Back���aler <br />Prevention Device rebale paymen's totalir� mora ih2n Su00 per c,alentlar year, and ��; il. <br />rzport fhe same payments to the Intem2l Revenuo Sen�ice. <br />I accept �he payment of ti�e Back�.ti�ater Frevention Devica r2bale frorn tho Cily o( Ever3tt penoing <br />approval of the completed f3ack�vater Prevention Device rebale package by the Ciiy of Lveretl <br />, //�L._! — — <br />Signature of Contraclor ___ <br />� �.�- l�- <br />Date <br />