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i <br /> i <br /> Gontractor Section: <br /> -- - - ---- � <br /> ---- ` <br /> l�l o�n I� ��N, h - �� LL� C-�b3 - �Ic�3 - �� � i <br /> IVendor Name/Business �'am '! UBI Numoer ! <br /> - M��� P P -t`-g'S ��-�- — � <br /> --- -- � <br /> Siafe of Nlashington Contractor License N,�mbec ' <br /> _ � �75 IS_'-f I`r SJ �!' Sno�o�n���. i.,,'!3- �tb2�u ' <br /> Vendor�lailing Address City State Zip � <br /> i <br /> �i��_��v _�`_f1�c� _ _ i��,.�3� �d �Mc�nf�lu,,.,h��� .c-:.� '. <br /> Phone Emaii i <br /> `- -- -- <br /> I, the Vendor,ogree to receive the Dackn�ater Prevention Devlce reLdle Chect tlL•ectly for the <br /> installation at lhe above referenced property address. dy agreeing to receive the rebate cLeck <br /> direcUy, I aoree lo Uie foliowirg: <br /> 1. The Backwaler Prevention Device rebate amount���ill be deducled front the final invoice � <br /> glven lo the property o�mer for the installaL'on at the proper;y address reterenced above, if � <br /> the tofal cost o(the instellaqon Is greatr.r than thc rebate. � <br /> 2 I, the Vendor, am a Washingbn Stalc licensed contrador. ; <br /> 3. The C;ty of Everett will scr.d a Federal Form �Q99 A91SC�o rre, the Vzndor, for�ackwater j <br /> Preventien Device rebale paymenls totaling more than $600 per calendar year, and will <br /> report the samr. �ayments to the Inlernal Revenuc Servicc. ! <br /> 1 accept the oayment o`the Dackwater Prevenlion Device rebate irom the City of Everetl pendiny �' <br /> aporoval of tho complcled Back�valer Prevention Device rebale psc4age bythe Ci(y of Evere,t <br /> i <br /> !� ,�,�/ i <br /> /� �-u-- �U – '.� –( Sr i <br /> — � <br /> � <br /> Signalure of Cuntraclur pa�� i <br />