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Contractor Section: <br /> I � ' �� �cc, � LLG �;3 �2'`t�3 <br /> �Cc,tr'� . .�c-�'�—�►r��.__, c.___�..L, _�'---- <br /> Vendor Name/ Busine s Name I UBI Number <br /> �.�"I��Z-�`� `.�� 1—K-�--- - -- -- - <br /> State of Washington Contractor l.icense Number <br /> ��Q� LC�I'_�1�--�Qa• —--�!✓��_�C�Q �'k_�i� <br /> i Vendor Mailing Address City State Z�P <br /> �ac��-Z_n��Q�_L��rxJ�_c�s�._aa� -�_���-_cor�- <br /> Phone Email I <br /> I _J <br /> � - -------------- ---- ----- <br /> I.lhe Vendor, agree lo receive Ihe Ciackwater Prevention Device rebate check directly for ihe <br /> instaflation at the above referenced properly address By agreeing to receive the rebale check <br /> direr.tly, I agree to Ihe following <br /> 1. The Backwater PrevenGon Device rebate amount will be dedu'��d Ssm��ee celd abovr., if <br /> given to tho property owner for thr,installation at the propeAy. <br /> the tolal cost ot thQ installalion is�realer than Ihe re�ate <br /> 2 I, the Vendor, am a Washinglon State licensed conlraclor <br /> 3 The City o(Evr,relt�vill send a Fedcral Form 1099 MISC lo mc,the Vendor, for Aackwater <br /> Prevention Device re�ents t ihe IntematlRe e�etServ 6e0 porcaiendar year, and will <br /> report the same pay <br /> II accr:pl lhe U�Yn�enl of Ihe B�ckwaler Prevvnlinn Device rebate frrnn the Cily nf Everett pendinc� <br /> approval ol the co��pleled 8ackwater Prevention Uevice rebate package by the City o( Everett <br /> . <br /> C����._�_ _C.������ - ----—_ .!�`� �-L-- - <br /> I - Dalr. <br /> Signature of Coniraclor <br /> i _ _. <br /> -- — — - --- -- <br /> -- --- -- --- - - - -- -- - -- - <br /> ,1 <br />