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Contractor Section: <br /> _Se�-��c�,_;���t1:+�;_�--� c--`-� �� 2U �,� l�D I <br /> Vendor Name � 9usiness Nam� / UBI �umher � <br /> ', — Se�vC`--� l- C11 l.c vv�S_ j <br /> �, Stale o(Washmgton Conhactor License Numher ' � <br /> � �_ � I �1�v�1(o � <br /> ! +�(�-�X--��� � r�n��c:� ��f�- <br /> , <br /> � Vendor Naihng �ddres5 C�'y State Z�p i <br /> ��_���0 14�S ----�����we�r _ri �,clfy, _ rr. i <br /> c � c�� i <br /> Phone Email ' <br /> I <br /> _ -------- — � <br /> I, lhe Vendor, agree to rPceive the Backwater Prevent�on Dev�ce rebate cheCk directly for Ihe <br /> m5talla!ion al Ihe above re'erena�d property address By agreein� to recerve the rebate check <br /> d��ecliy, I agre? to the lollowing <br /> 1 The BacY.water Preventio� Oevir.e rebate amount wiu be deducted from the Gnal invoice <br /> given to Ihe property owner for the installaLon at the properly address re�erenced above it <br /> fhe tntal cost o(thr. mstallahon is greater than the rebate <br /> 2 i, the Ventlor, am a Washington State I�censed conlracror <br /> 3 The City of[verett will send a Federal Fo�m 1099 MISC lo me, the Vendor, (or BackwatPr <br /> ?reven6nn D?v,ce rebate payments totalmg more than 5600 per calenda� year, and t�,il. <br /> report fhe same payments to the Intemal Revenue Serv,ce <br /> II accept the payment ot the t3ackwale� Prevenhon Device �ebate from thr. Cdy o�Everett pending <br /> I approval ol the completeA Backwaler Prevenhon Dev�ce rebate package by !he City o1 tverett II <br /> � <br /> i <br /> 'i fG �f'l,�'_ .�-C.. 7�-i .��—�' — -- I <br /> Signature of Cortractor Dale , <br /> ii <br />