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Contractor Section: <br />k�3 —Gl 3 —CUSS? <br />Vendor Name / Business Name I tJBI Number <br />State of Washington Contractor License Number: <br />"14vN,- Mir vs UZlZ.; wj <br />Vendor Mailing Address City State Zip <br />' 7 --%6'0 7 <br />Phone Email <br />I, the Vendor, agree to receive the Backwater prevention Device rebate check directly for the <br />installation at the above referenced property address. By agreeing to receive the rebate check <br />directly. I agree to the following: <br />1. The Backwater Prevention Device rebate amount will be deducted f,•, '! . final invoice <br />given to the property owner for the installation at the properly address referenced above, h <br />the total cost of the Installation is oreater than the rebate. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. The Clty of Everett will send a Federal Forr 1 99 N4ISC to me, the Vendor, for Backwater <br />Prevention Device rebate payment . 'a ., ore than $600 per calendar year, and will <br />report the same payments to the In : • . •nue Seriice. <br />I accept the payment of the Backwater Prevention Device rebate from the City of Everett pending <br />approval of the completed Backwater Prevention Device rebate package by the City of Everett <br />Signature of Contractor <br />s -C;:)-fs <br />Date <br />