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Contractor Section: <br /> S7)�r� I � % Sc_1���' S-- (��- � �' z � - ' % <br /> - �--�1�---3� _ __ <br /> Vendor Name/ Business Narne / UBI Number <br /> � 7-� � c �.� �•) z •� _J �� <br /> Slate o(Washington Conlraclor License PJumbec <br /> _ _ _ _ , - . , - ..%� `%TS ?�'�.� <br /> Z ���� � C� � /� r tiii>L _�`�i�.'i`L_ __�i�����,�1,�-�� ISL L — <br /> Vendor Pfailiny Address City State Zip <br /> I/Z� �/1�5--71`iz _ _StC__` � �,�, 5,'�.� �. ,_ �? /�� i-�.,�;. 1. ����1 � <br /> Phone Ema�,l <br /> ------- _ -- -� � <br /> I, the VenAor, agr;e lo receive lhe Backwater Prevention Device reDate check dheclly (or Ihe <br /> mstallation at the above referenced property address By agreeing to receive the rebate check i <br /> directly, I agree to Ihe(oUowing <br /> 1. The Backwater Preveniion Device rebate amount wdl be deducted (rom Ihe tinal invoice <br /> given lo the prnperty owner(or�f�e inslallation at Ihr. property address refsrenced above, if <br /> lhe total cost of lhe inslallatron is greater than lhe reba�e. <br /> 2 I, tha VenAor, am a Washington Slate lir.ensed coniractor. I <br /> 3 The C�ty of Cverett wdi send a Fedeial Form 1099 t�41SC to me, the Vendor, for Backwater <br /> Prevrntion Device rehate paymr.nts IolaGng more Ihan 5600 per calendar year, and will <br /> i��por! lhe same payments to the Internrd Revenue Scrvicc <br /> I accepl lhe paymenl af the D2ck�valer Prevenhon Dewce rebale trom th� City of Cverelt pending <br /> approval of Ihe cornpleted Backaialer Prevention Uevice rebale package by the Ciry ol Cvercll <br /> � <br /> r • _. _�— G� - l� - l� <br /> _�i /'�r �1- - -- - - — <br /> Signature of Contractor Dale , <br />