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Contractor Section: <br />Vendor Name / Business Name / UBI Number <br />State of Washington Contractor License Number. <br />Vendor Mailing Address City State Zip <br />.1zzs-- 4b'q-olZ3 , P/,,Mbiv`gUCatt�671r+il e,-- <br />Phone Email <br />_ .. _._ — _.... ;.d : Device rebate check directly for the <br />installation at the above referenced property address. By agreeing to receive the rebate check <br />directly, I agree to the following- <br />1. The Backwater Prevention Device rebate amount wi.11 b:, u- Inn- uivun.iw <br />given to the property owner for the installation at the property address referenced above, t <br />the total cost of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. The City of Everett will send a Federal Form 1099 MISC tome, the Vendor, for Backwater <br />Prevention Device rebate payments totaling more than $600 per calendar year, and will <br />report the same payments to the Internal Revenue Service. <br />I accept the payment of the Backwater Prevention Device rebate from the City of Everett pending <br />approval of the completed Backwater Prevention Device rebate package by the City of Everett <br />Sign cf Contractor Date <br />