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Contractor Section: <br />� l��L_�� <br />Ver,�or Name / <br />,,, <br />/ UBI Number <br />��Ll_'G-S�3-G� -- - <br />Stale of Washington Contractor License Number. <br />. <br />Syoy �� /J�e �✓'% --i"'ariSL%;�c� _w9� <br />Vendor Wiailing Address CYty <br />3�7� ! <br />Phone <br />Email <br />0 <br />_��'•" L 7� <br />State Zip <br />I, the Vendor, agree to receive lhe Backv✓ater Prevention Device rebate check direclly tor Ihe <br />inslallalion at Ihe abo�e referenced property address By agreeing to receive lhe rebate check <br />directly, I agree tu lhe lollok�ing <br />I <br />— J <br />t The Back�vaU:r PreveMion De�ice rebale amount will be deducted from the final invoice <br />gwen to the property o�vner for lhe.inslallat�on at the property address re(erenced above, d <br />the total cosl of Ihe inslalla.':.,n is yrealer lhan the rebate. <br />2 I, lhe Vendor, am a Washingtan Stale licensed conlraclor. <br />3. The Cdy of Everetl v:ill send a Federal Form 1095 M�SC lo me, the Vendor, for Backr�aler <br />Prevenlioc Device rebate payrnents tola6ng morc than $f00 per calendar year, and �vill <br />report ihe same paymenls lo ihc Inlcrnal Revenue Service. <br />i accept the payment o( the Backwater PrevaiGon Device rebale from the City of Everett pending <br />approval of the completed 8ackwater Preven�ion Device rebate packaye by lhe City of Everett <br />— �/ Z '� <br />Signalure oi Contractor _ Date <br />