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Contractor Section: <br />` � �c%.�`���:'l' —1c ' � 2�'r— ` <br />�ia�i�-� -x -- -��-5 t , � LLC. �G _� 3_ �.3 <br />Vendor Name 1 Busine�ame / URI Number <br />A��-�1� ��—f>-� ------ --- — <br />Slate of Washinglon Contractor License Number. <br />_�lw�_(Q L-a rli�1—� P�. � tJ�re't�" __. L�-��-- �i"�f:�a3 <br />Vendor Mailiny Address Ciry Stale Zip <br />a�����a��a-�►�at_r_��:�._a��,_���. �� _ <br />Phonc Email <br />I, the Vendor, agree to receive the Rackwaler Prevention Device rebate check diiectly (or the <br />inslallation at the above referenced property address. By agreeing to receive the re6ale check <br />direclly, I ac�ree to the (ollowing: <br />1. The 8ackwater Prevention Device rebale amount will be deducted from lhe final invoice <br />given to tha proporty owner (or the installalinn at the properly address reforenced above, iF <br />lhe tolal cost of ihe installalion is preater than the re6ale <br />2. I, lhe Vendor, am a Washington State licensed contractor. <br />3. TI�� Cily of [verett �vil! send a Federal Form 109� MISC 10 mc, Ihe Vendor, lor Backvdaler <br />Provention Dovice reb�tc p�yments totaling more G��n 5600 per r.alendar year, and �vill <br />report ihc samc payments lo the Inl�rnal Revenuc Service. <br />I accept thv payment oi the Backwaler Prevention Dovice rebale f�om iho Ciry o` Everell pendiny <br />,�pproval of Ihe compleled f�ackwater PrevuHion Dewce iebate par.kac�e by Iha Cily of Everett <br />l�t:c l -- - �- — J <br />. 1-��_ C�'���-C. ---�'�-�f�^� , <br />Sic�nalure of Conlraclor Oate <br />