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1 <br /> � <br /> Contractor Section: I <br /> — - -- -- - I <br /> � _ --- <br /> � 1'`�� L��r1-�l_� ( �� ------ ���-�=�e'�--�I�j <br /> 2�. � � <br /> Vendor Name/ Busine�pl-ame / UBI Number <br /> � _�#-��1�'D/LP� ----- -- -- - <br /> IState of ashinylon Conlractor License Number. <br /> ! �� GL _1/l��u:l���t .�_ � :i —� �o{G � <br /> � Vendor Mailmy Address Cdy Stale Lp i <br /> � <br /> � <br /> -�1��=�1��_a�z�__��/L��1�,_�-�4 //C . �,�(. <br /> ��__ <br /> Phone Email i <br /> I, lhe Vendor, agree to receive the Backwaler Prevenlion Device rebale check directly For the <br /> instaltation al the above referenced property address. By agreeing lo receive lhe rebate check <br /> directly, I agree to Ihe lollowing � <br /> 1 The Backwater Prevention pevice rebale amount will be deducled from the final mvoice <br /> niven to the propeAy owner lor the installaUon at the property address referencod above, if, � <br /> lhe tolal cost of the mstallaUon is greater than the rebate. <br /> ? I, the Vendor, am a Washinylon State hcensed contraclor. <br /> 3 The Cdy of Everett will send a Federal f orrn 1099 MISC to me, Ihe Vendor,(or Backwatei <br /> Prevention Device rebate payrnents tota4ny more than $600 per calendar year, and will <br /> repotl ihe same paymen�s to ihe Intemal Revenue Serwr,e. <br /> � I acce.�t the payment of the Back��ater Prevention Device rebale frorn Ihe City of Everett pendiny <br /> approval of the cnmpleled Bar.kwaler Prevention Dcvice rebate package by �he City af Everotl i <br /> I <br /> � —� I <br /> '�___ ��S/5 <br /> Signatwe ol Con�ractor Dale I <br /> � . - - - -- — -- - - <br /> -J <br />