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Contractor 5ection: <br />��.GL�Q�Lu, M j_i.�LG (� >-- oi 3- � S�' <br />Ver,dor Name 1 Business Name / U�I tJumber <br />�1 Ll� F'L_ �c. �_L� _ ,. ___ <br />Statc o( Washington Contracfor License Number. <br />S� �� j~f� v1 NG /h /�1_ZY 5 iJi1.Gi:—�/�'._�_.�5� s.� �' .-- <br />Vendor ��qailing Address City State Zip <br />�/ z � '�,? _-1��7 <br />Phone ' Email <br />I, ihe Vendor, agree to receive the 132ckvdatsr PreveMion Devica rebale check direclly for the <br />i, stallation at the above referencod property address. By agreeing to receive the rebate check <br />direclly, I agree tn lhe follo�ving: <br />1. The Back��oater Prevenlion Device re6ale amount will be deducled irem !he final involce <br />oiv�n tu lhe pioperiy o�vner for th� inetallalion at ihe property address referenced above, if <br />the tolal cost oi fhe inslallation Is grea�er tnan lhe rebat2. <br />2. I, the Vendor, am a WasLington Stata licansed conlractor. <br />3. The City oi EvereU �vill send a Federal Form i 099 NISC to me, tho Vendor, for Backwafer <br />Prevenlion Device rehatr. paymenfs tctaling mere than S6D0 psr calendar year, and �vill <br />r�port !he same paymenls to ihe Internai Revenue Servi; e. <br />I accepl ,he paymont o( the Bar.kv+ater Prevr.nlion Device rebate froin lhe Cily of Everett pending <br />,�ppioval of the coiriolefed Rack�vater Provention Device rebate package I�y the City nf Fverett <br />— U'.— _�—� <br />Date <br />