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Contractor Section: <br /> � �YU�-�— `���_ �- �{��;������tcXli �C� /�,,r�?> _.;lsr�?.3�5 <br /> � Vendor Name I Husine§s Name I UBI Number <br /> I <br /> _,�1�'L� F>L��`�--`.�-� 1 l� � -- - - - - -- --- - - - <br /> , _ <br /> Siate of Washington Contraclor License Number: <br /> �(vn�._ Lar_I�j'1_ ��=--�t✓_�-c_e�i'_ _��.7�� _���.��� � <br /> Vendor Ma��ing Address City Slate Z�P <br /> '�L,�-�C(n�?�q� ---L1ftcli Cl c�:3��-�C ��pD�-C'�t?2_- I <br /> Phoro Emaii <br /> I� - ---_ _---- — ----- — -- -- - -- — I <br /> I, Ihe Vendor, agree to recelve the Bar.kwater Prevenlion Device rebate checK direcl'y icr ;he I <br /> ins'a'lation at the above referenceA property address. Ry agreeing to reca�ve Ihe iabate check <br /> direclly, I agree to Ihe foilowing <br /> 1 The Backwater Prevenfion Device rebate amount will be deducled from "" final invoice <br /> given lo the propr,rty ovmer for thc installation at Ihc propr,rty address re �nced above. i� <br /> the tot�i cnst of thr, mst:�llalion is groater than Ihr rebate <br /> 2 I, Ihe Vendor, am a 'Aashinglnn Statc lirensed conindcr. <br /> 3. The City o(Fverctt wiil send � Fr.deral form 1099 Mi,^,C lo mc, ihe uendor, for Rar.kwatcr <br /> prevention Device rebate payments totalinc� more lhan $fi00 per calendar year, and w�ll <br /> repoR the same payments to Ihe Inlernal Rcvenuc Scrv�ce <br /> I accept thc paYn'ent ol the Backwaler P�evenUon Device n:bat�from the Ciry of EvP�ett pending <br /> approval oi the compleled Backwater Pievention Uevice iehale packa9e ��Y ���''Gty o(f-verett <br /> (�c`��..�._��r�� --- — -- -- Ll.��`�-�.�'S— - I � <br /> � Dale <br /> ' Signature ot Contractor <br /> ' — - <br /> � - -- - - — <br />