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Contractor Section: <br />Vende� Name ! Busine�s Name / UBI NumbPr <br />� U � ' � `a��-t�ZL--�-�- - <br />State of UJashington Contractor License Number. <br />�2(�1`i�—��.�_C_�.i�1--L1 Pa. �b1t'.rP'1-t��,�.�� ��• <br />Vendor Mailing Address Ciry State Zip <br />Phone Email <br />I, the Vendor, agree lo receive the Backwater Prevention Device rebale check directiy tor the <br />installation at the above referenced property add�ess. By agreeing to receive the rebale check <br />directly, I agree to lhe follotving: <br />9. The Backwate� Prevention Device rebate amount will be deducted from the final invoice <br />given to the properly owner for the installation at the property address referenced above, if <br />fhe lolal cost oi Ihe installalion is c�realer than Ihe rebale. <br />2. I, the Vendor, am a Washinglon Stale licensed ccnlraclor. <br />3. 7he Ciry oi [vcrett will send a Federal Form 1099 MISC to me, lhe Vendor, for Backwater <br />Prevention Device rebate payments tolaling more than $600 per calendar year, and will <br />report the same payments lo the Internal Revenue Service. <br />I accept ihe paymenl of the Bacic�valer Prevention Devico re�ale from the City of Everett pending <br />approval of the completed dackwater Prevention Device rebate package by Ihe City oi Everett <br />� � �...�� �-1�- <br />Signature of Contractor Dale <br />