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i <br /> � <br /> . ; <br /> � <br /> i <br /> I <br /> � <br /> � <br /> i <br /> Contractor Section: . � <br /> � <br /> � � L �LCJ� � _cC�-•.�Lur+�L�LL�I"r..���G-'` � -�� � <br /> j �1'�'ir-� �- � � i <br /> ' Vendor Name! 6�sine s N��me/UBI Number r <br /> ��_�-F-':5��`�-�`3-�-i---K��---- � <br /> State of Washingmn Contractor License Number. � <br /> I <br /> �����j�_ae,��r��i+_�.��������%� � <br /> Vendor Maili�g Address City State �ip � <br /> aQ�r�.= ��t��L��_n'��iL� •C�E'_v2�?.�_ r� � ��1Q0, l'r,�'I'1 _ I <br /> Phone Email ; <br /> i <br /> I, the Vendor, agree lo receive the Backwater Prevenlion Device rebate check directly tor the <br /> installation at the above referenced properiy address. By agraeing to receive the rebate check ! <br /> directly, I agree to the following: � <br /> 1. The Backwater Prevent�on Device rebale amount will Le deducted from the final invoice � <br /> given to the property o�vner tor the installation al the property address re(erenced above, iF , <br /> the lotal cost of Ihe installatior. is greater than Ihe rebale. � <br /> 2. I, the Vendor, am a Washington State liceosed contractor. ! <br /> 3. The City of Fverctt v,ill send a Pederal Fonn 1099 MISC lo me, the Vendor, for 8ackwater � <br /> Prevention Device rebate payments tolaling more tl�an 5n00 per calendar year, and will � <br /> report the same paymeNs to the Internal Revenue Service. ; <br /> i <br /> ----- - --- i <br /> --- - - — --- i <br /> I accept the paymenl of Ihe Back�valer Prevention Device re�ate from the Ciry of Everelt pendin� � <br /> approval of the compleled Backwaler Prevention Device rebale package by ihe Gity of Everett i <br /> I <br /> � <br /> ���_ I <br /> C..��•s,.�"--� --�---`.�.-'„"—`)---- i <br /> Signature of Contraclor Date � <br /> i <br /> � <br /> _ - -- � <br /> i <br /> l <br /> ! <br /> � <br /> i <br /> i} <br /> f <br />