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i <br /> i <br /> I <br /> Contractor Section: j <br /> -__" _ __-__ `__�___-... __ _ _.___.__ _ � <br /> ' � <br /> _/,�li/_(1LCJ__/"�lGNI�� �,�Jv /�j -<ii 3 - �SSl <br /> I Vendor Name I Business Name I UBI �umber i <br /> � <br /> � 'Lci1._L�L <<'_C�. ------- i <br /> State of VJashing,on Contrac!or L cense N�mbar. ' � <br /> jr <br /> S L7_11��_--^�L-- -- ���1�5�5�'�l�i:_ v/f _��Lr__ I ' <br /> i Vendor tvtailing Address City State Zip • I <br /> � ��SL���f,�c�7 - - --- i <br /> Fhone Email <br /> '- — — J <br /> !, t�e Vender, agree to rece���e th= Bach�;�aler PrevzN�on Device reba;e check d'rectly for the <br /> nstaUat�on at tns abo��e referenced prooerty atloress. By agreeing to receive the rebate check � <br /> tlireCUy, I aaree to the foltowing: <br /> 1 The Back.vater Prevention �evic. rebate a�eunt�:�'.0 be deducted from ;ne fir�al mvolce <br /> given to t7e property or:ner for the installat�on at the propert,�address re`erenced above, 1f <br /> !he total cost of Ihe insfallaGon ia orr•at2r than the rebate. <br /> 2 I ;h= Vendor, am a l4�ash'maton Sta;e licensed contraclor. <br /> � <br /> 3 The City o`E��erett v;ill ser,d a Federal Fcrm 1095 t�41SC to me, Ihe Ve.rdor, for Bar.4i•�ater � <br /> Prevention Devico rebate payments totalirp more than $6D0 per calentlar year, and tivill <br /> rzucrt the same paymenls to the In;ernal Revenue Service. <br /> � <br /> I accept the payment of the 8ack�•+aler Preventlon De��ice rebale irnm the Cily of Eveiell pending <br /> Iapproval of the completed Back���aler Prevenlion Device rzbale par.kage by!he City o`E��ereti <br /> , � � <br /> i'� _ _ -t�_5/ir' I <br /> .� <br /> Signalure cf Contractor � . Date <br /> ' — -- --- i <br />