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Contractor 8ection: <br /> �t/iu�� P�,,,-.� �o �- �fr5 �2 <br /> —--- _ __------- — ---- <br /> Vendor Name/Business ame / UBI Numbcr <br /> I / ' uU1 J�1 '� _���_U — _ _ . _ _ ---------- -- <br /> Slate of Washmgton Contractor License Numbec <br /> -�-'�I �_�-(r �si s 'V --�-�!�e�.•,� Wp �"z�'o--- <br /> Vendor Mailing Address Cdy State Zip <br /> ��-� 7�0 �5��_� 'r/�� hc�t��u�, .cu.... i <br /> -------- --- --- -- <br /> Phone Emaii I� <br /> - -- —— -- ------- -- �� <br /> I, the Vendor, agree to receive Ihe Backwater Prevention Device rebale check directly for Ihe <br /> inslallaUon al lhe above referenced property address By agreeing lo receive the rebate check <br /> directly, I agree to the followmg <br /> 1. The Backwater Prr,vention Device rebate amount will be deducted trom lhe final invoice <br /> given to the properly owner for the installation al the property address refarenced above, if <br /> the total cosl of Ihe installation is greater than the rnbate. <br /> 2. I, �he Vendor, am a Washington State Iir,enseA contractor. <br /> 3 The City of Everetl will send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br /> Prevenlion Device rebale payments lotaling more than $600 per calendar year, and will <br /> repoA the same payments to the Internal Revenue Service <br /> I accept lhe paymen�of the �ackwaler Prevention Device rebate from Iho Cily ol Everelt pendmg <br /> approval of the completed Oackwaler Prevention pewce rebale package hy the City ol Everelt <br /> �i2f �'�--�_- --- y�� i= i�---- - <br /> Signature of Contractor Date <br />