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i <br /> � <br /> i <br /> Contractor Section: � <br /> — ----- — — - - — � <br /> l�'� oc�.n I�I �� b ��� [. L % G�U3 _ �1 �3 - f��,�� � <br /> Vendor Neme/Business Nam I U41 Numher ; <br /> I <br /> MUcJr PP � g� �� - - - -- � <br /> Slate of Washinyton Contrac,.. .icense Number � <br /> I 7 5 i S `�� sJ 5(= �n�h��+,� ��. �-✓�1 ��Zw C� � <br /> - �--- ---- ' <br /> � <br /> Vendor Mailing Address City State Zip i <br /> � <br /> H�1- 7vu �l�v.-- 'i,�.�,,�d �a r�-to�•.r.��tiN,h�„ .�.�.;., ; <br /> __ i <br /> Phonc Finail J ' <br /> � <br /> I <br /> I, the Vendor, ngree lo receive C�e Backwater Prevention Device rebato check direclly for lho <br /> installation at ihr,above referenced property address. By agr�eing lo receive the rebale check <br /> dircctly, I agree to the(ollowing. ; <br /> 1. The Backwa(er Pievention Device rebate amount will be deducted from the flnal invoicr. ° <br /> given ln the proprerty owner for tho installallon at the property�ddress reforenced above, i( j <br /> Ihe total cost of the inslallalion is grealer than the rebate. <br /> 2. I,lhe Vendor,am a Washington St�te licensed contraclor. � <br /> 3. The City of Everetl will send a Fedcral Form 1099 MISC lo me, ihr.Vendor, for Back�a'ar � <br /> i <br /> Provention Device rebate payments totaling more than$600 per calendar year, �nd wiP <br /> report thr ,ame payments to the IMemal Revenuc Service. ' <br /> --._ ._ . � <br /> I accept Ihe payment of the Hackvmter Prevenfion Device rebnte from the Cily nf Fverett pending � <br /> apprnv�l ul Ihe compluled Onckw�der Prevention Urtvire rel�ale packago by Ihc�Cdy of Gvr.mlt i <br /> �� � �---�---- ;�_ � _ ,s-- ; <br /> � <br /> iignature of Coidrar.lor Uate j <br /> i <br /> � <br /> i <br /> i <br />