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Contractor Section: <br />�'-'` �P�-�3 <br />Vendor Name ! Business Name / UBI Number <br />�_.I�1��.�� '--�,-1-� � <br />State oi Washington Contractor License Number. <br />��"/�O ��ll��il� ,--�—SV N !'i� 11 l t✓cf "Z. <br />Vendor Ntailing Address City State Z�p <br />Phone Email <br />I, the Vendor, agree lo receive the Back�vater Prevention Device rebate check directly for the <br />installalion at the ahove referenced property address. i3y agreeing to receive the rebale check <br />direcUy, I agroe to the foliowin�� <br />i. The Back�vater Prevenlion Device rebate amount vriil be deducted from lhe Gnal invoice <br />given to lhe property owner for the inst.allation at lhe property address re£erenced above, if <br />the total cost of Ihe installalion is greater than the rebale <br />I, thc Vnndor, am a Washington State licensed contractor. <br />The City of Everett will send a Federal Fonn 1099 MISC to me, thc Vendor, for Rackwater <br />Prevention Device rebate paymenls tolaiing more than $600 per calendar year, and will <br />report lhe same poymenls to Ihe Internal Revenue Service. <br />I accepl Ihe payment of the Backwater Prevention Davico rebate from the City of Everett pending <br />approval of the compieted Backvoater Preventlon Device rebate pa�kage by the City of Everett <br />C�t'.,r�—�_.u'-�� ,_ �.�� f�1 _ <br />Signature ot Contractor Dale <br />L�---- --- — ------ ---- --- <br />