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Contractor Section: <br />�----- — -- <br />� � , �.. <br />�i�^iC.u:1�--�': ��C���t_zi.�—.,H� <br />Vendor Name ! Busine�s Name / UBI Number <br />� _�L�-�= 5-�-�-��K�1' - <br />I.5late of Washington Contractor LiCense Number. <br />Vendor Mailing Address <br />Phone <br />Email <br />City Slate Z�p <br />I, the Vendor, agree to receive the 8ackwater Prevention Device rebate check direcily for Ihe <br />in;tallation at the above referenced property address. By agreeing lo receive lhe rebale check <br />direcUy, I agree to the foilowing: <br />1. The 8ackwater Prevention Device rebate amounl will be deducted from lhe final invoic� <br />given to lhe property ovancr for the installation at Yhe property address referenced above, if <br />lhc total cost of the installation is grealer than ihe rebate. <br />2. I, Ihe Vendor, am a Vdashinglon State licensed contractor. <br />3. The C�ty of Fvereri will send a Federat Porm i099 MISC to me, Ihe Vendor, for 6ackwater <br />Prevention Device rebale paymenls totaling more than 5600 per c.alendar year, and will <br />report the same paymenis to lhe Intemal Revenue Service. <br />I accept the payment of the Backv�atr�r Prevention Device rebate from Ihe City of Everelt pendinp <br />approval o(the compieted Backwater Pievention Device re�ale packa�e by lhe Clty of Fverelt <br />, <br />�� � ��-- <br />Signature of Contractor <br />--��� 1�a-- <br />Date <br />