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i <br /> : <br /> � <br /> � <br /> , <br /> . <br /> ; <br /> Contractor Section: i <br /> - - � <br /> ,{ i <br /> F7ii�..+-�*^��--�"��'-�_f' 4"�41''/`����ri� -�4 v�� j <br /> Vendor Name!Business Name/UBI Number � <br /> �}MC��T'=.SS �oL�,l_ _ � <br /> i <br /> State of Washington Conlractor License Number: � <br /> .�[�, ���-�,l1� Ei r� ��5��� i <br /> Vendor Malling Address City Slate 'Zip i <br /> �1 n" .�.IQ _ ��'•Rr�. ��'�r'1rI:i�Gv1�711�1�'C[t�'I.�v�,�.SidiE ' .CcDy7 <br /> Phone Email <br /> ; i <br /> — -- _ � <br /> I,the Vondor,agree to receive lhe Bacicwater Prevenlion Device rebete check directly far the i <br /> ins1a11a1ion at the a6ove referenced property addrass.By agreeing W receive ihe rebate check <br /> � direcUy, I agree lo the tollowing: � � <br /> i i <br /> 1. The Backwater Prevenlion Devlce rebate amount will be deducled fmm the final invoice � <br /> given to lhe property owner for the installaUon at the property address re(erenced above,If ; <br /> the lotal cast o/fhe installation'is proater�han ihe reGate. � <br /> �. I,the Vendor, am e WasM1ington Slnte Ilcensad conhactor. <br /> 3. The City of Evere@ will send a Federal Form 1099 MISC to me,lhe Vendor,for Backwalor <br /> Prevention Device rebete paymenls lotaling more Ihan$600 per calendar��ear,and will � . <br /> report Ihe same paymonts to the Intemal Revenue Service. � I <br /> I uccepl Ibo paymont of the Uackwaler Proven�ion Uevice rabalo(rom the Ciry of Everett pending � <br /> approvel ol Ihe completeA Backwater Prevenlion Oevice rebate package by lho City ot Evere�l <br /> i <br /> � � �� S� 1L�.L-c�L�- <br /> Slgnature of Contrac1or Date � <br /> � <br /> � <br /> I <br /> i <br /> I <br /> I <br />