2417 PINE ST 2016-01-01 MF Import

i i ; , i ; I Confractor Section: ` � j � L[..r�"�Gc_n . I /��% i- �ii�.�/rr (-z�� -ri/ � - �S SI ! Venoor Name I Business Name/UBI Number � � i � ` /-'rrl� f'� !Ci'��f _ _ i _ � State of Washington Cor�tractor License Number: � .�`L!�/'—~/Q'i1� /✓i-'. _ /l��/�y� '�I.L//-�l= �/1//� ��iCJ � Vendor Mailing Address City State Zip ry i ; ( -, �� / :..�/��''�_C/7 . Phone ' Email �-- --- -- � ; I, ihe Vendor, agree b receive Ihe Backwater Prevention Device rebale check direclly ior ihe ` ins!ailation at ihe above referenced propery address. By agreeing to recelve the rebate check directly, I agree to the tollo�vina: ' 1. The B�cMvater Prevention Device rebate amouM�vill be d?ducted irom ihe final invoice given to the propeity o�n�ner tor the installation at the property address referenced above, if � the total cosl of ihe inslallation Is greater than tl�� rebate. � ?_. I, the Vendor, am a Washington SGie licensed contractor. � 3 The Ciry of Everett vrill send a Federal Form tC99 NISC to me,the Vendor, for Backtva!er Prevenlion Device rebate payments btaling more than 5600 per calendar year, and �vill report the same paymenls lo the Inlernal Revenue Service. i I accept the payment of the �ack�vater Prevention Device robate irom ihe Cify of Everolt pending , appmval of the completed Backeiater Prevenlion Device rebata package by the Cit9 of Evereft I I . rJ C� �-�� SiqnaWre o(Contracior __ . Date f ---- — --- -— - — -- - � ';