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� <br /> � <br /> } <br /> i <br /> � i <br /> Contractor Section: <br /> � , _ ,. -, > � <br /> ��l.�U—��GI�M > �. Nv (�.> -r�l � - C�SS�, � <br /> Vendor Name/Business Name/UBI Number <br /> ; <br /> ��L ' o'-L'' I <br /> I 5tate of Washington Coniraclor Licens? Number: I <br /> .S`/OJ 7/j~f}V� N� MAIZYS i/i/1.�= lN/i ��i�7�/ � <br /> Vendor Mailing Address City State Zip � <br /> `��. � )�i � "jOC17 � <br /> � Phone Email <br /> � <br /> I,Ihe Vendor, agree to recslve the Backwater Prevention Device rebate check direcUy for the � <br /> installation at the above referenced property address. By agreeing to receive the rebate check � <br /> directly, I agree [o the following: ; <br /> i <br /> 1. The Baok�vater Prevenlion Device rebate amount�+�iil be deducted irom the final invoice <br /> given to the property oa-ner for the installation at the property eddress referenced above, if <br /> the total cost of Ihe installation is greater than the rebate. € <br /> 2. I, the Vendor, am a Washfngton State licensed contractor. <br /> 3. The City of Everett v,lll send a Federal Form 1099 NiISC to me,the Vendor, for Backwater � <br /> Prevention De��ice rebate payments totaling more ihan�6D0 per calendar year, and�vill " <br /> report ihe same payments lo ihe Inlemal Revenue Seroice. ; <br /> 1 <br /> i <br /> I accepl the p2yment of the Back�vater Prevenlion Dcvice rebate trom the Ciry of Everelt pending ! <br /> approval of the comploled Back�vater Prevention Device rebate package by the City ot Everett <br /> � <br /> � � i5 � <br /> Signature of Contraclor Date � <br /> � <br /> � <br /> I <br /> I <br />