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� <br /> � <br /> � <br /> � <br /> I <br /> Contractor Section: � <br /> r— -- - --- --- � <br /> W��' � � �SN..«�' LLC- la,'c•-'�3 I <br /> Vendor Name I Busine�s Name/UBI Nurnber � <br /> /,1 i <br /> A �r � hT ���t(,�-.Kr�_--'- ` <br /> State of Washington Coniractor License Number: <br /> ��,�(o La,c'1i�`1�$> �WF.r��j����1�a2o� � <br /> Vendor Mailing Address Cily Slate Zip � <br /> � <br /> ar�-;�:�n�ansa G'�ad�cLc:��� •J��Cot22_ ! <br /> Phone Erti�il ` <br /> � <br /> - — i <br /> I, ihe Vendor, a�ree to receive the Backv�aler Prevention Device rebate check directly for the ' <br /> , <br /> installation at the abovc re(erenced propeAy addross. By egreeing to receive the rebate check ! <br /> directly, I agree to the following: 1 <br /> 1. The Backwater Prevention Device rebate amount wiil be deducted from the final Invoice � <br /> given to Ihe property owner for the installalion at the property address referenced above, i( i <br /> tho lotal cosl of the inst:illation is{�reate:lhan ihe rebale. i <br /> 2 I,tho Vendor, am a VJashington State licensed contractor : <br /> � <br /> 3. The City nf Evereft will ::end a Federal Form 1099 MISC to me, the Vendor, for Backwater i <br /> Prevenlion Device rebale paymonts totaling more than $600 per calendar year,and will <br /> report the same paymenls to the Internal Revenue Service. ( <br /> I <br /> --------- -- � <br /> I accept the payment oi the Backwator Prevenlion Devico rebale from the Cily of Fverett pendine� I <br /> approval of lhe completed Backwater Prevenlinn Device rebale package by the City of Everett � <br /> i <br /> I <br /> l�C.[ . � -� -- � <br /> 5ignaWre of Contractor Dale I <br /> � <br /> ----- - 1 <br /> __ � <br /> � <br /> i <br /> � <br /> 1 <br /> ( <br /> I <br />