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� <br /> � <br /> � <br /> i <br /> i <br /> � <br /> Contractor Section: � <br /> I <br /> I -' ' Cfl L1.L.-u ly�/17/7 L /U!Y liX J� '-U/ j ' C%S�f f i <br /> iVendor Name!Business Name/UBI Number f <br /> /� ,� � � <br /> / !�lL-L f", C�? J — � <br /> Si�te of UJashinaton Contractor License Numoer. � <br /> � <br /> ��7 7/s ' v� N�, �!�/�IsYSv�IJ; l,�/� ��s"?7a ; i <br /> Vendor A�ailing Address City Siate Z�p � ; <br /> I <br /> � i <br /> � `� �s �= � ��--- _ � <br /> � Phene ' Email : <br /> � _� � <br /> I, [he Vendor, zgree to rece:ve the B2ckvaafer Prevenlion Device rebata check direclly for th2 ! <br /> instailation .at the above referenced prope�y address. By agr�eing to reczive lhe rebate check <br /> dlrectly, I agree to ihe folio���ing; ! <br /> 1 The Back�vater Prevantion Devica rebate amour,;will be deduded irom the final invoice � <br /> given ro the property ov+ner for the inslallation et the property address referenced above, ir <br /> lhe total cost oi the insfallation is greater than the rsbate. ; <br /> t <br /> 2 I, the Vecdor, am a l4�ash;ngton State licensed contractor. � <br /> 3. The City or E��erett will send a Federal Form iD99 DiiISC to me,tho Vendor, ror Bac!n:ater � <br /> Prevention Devics rebale paymenls totaling more than So00 p=r calendar year, and�t�ill j <br /> report the same paymants to the Internal Revenue Service. � <br /> ( <br /> -- — � <br /> I accept the payment of the Dac4water Prevention Device rebate from the Cily of EvereL` pendiny � <br /> approval of the compleled Backe+ater Prevention Device rebate package by the Ciiy of Everett � <br /> i <br /> ! <br /> � ! <br /> �._�� �,� - 1 - ts � <br /> � <br /> Signature of Contractor „ D2te � <br /> 1 <br /> — — � <br /> I <br /> � <br /> i <br /> t <br /> � <br /> � <br /> I <br /> { <br />