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i <br /> ; <br /> , <br /> i <br /> Contractor Section: � <br /> -- — ----------- i <br /> ' /7��/��-CLLf.'•/r �': �?�3 G� 7 U.S� I . <br /> !iendor Name/Business Name/UBI Number <br /> � /}�'�'iC� �_�GJ — - - � <br /> S!ate o(Washington Conlraclor License Number. <br /> . � <br /> �L/G7 �% �UCi Nli Mu,��SU�i/C. 1N/J' ��f.���J _ <br /> i Vei�dor hlailmg Address City State Zip <br /> � 3��-/S� 7 � <br /> � Phone Email � <br /> i <br /> � <br /> I, tl�e Vendor,agree to recerve the Backwaler Prevenlion Device rebate check directly for ihe ` <br /> ,nstallafion al the above reterenced property address. By agree�ng lo receive the rebate check � <br /> direc0y, I agree to lho following: <br /> i. The Backe�ater prevention Device mbale amount will be deduc,ed (rom lhe Tnal invoice ' <br /> given to Ihe properly owner for the installation al Ine property aCdress referenced above, if <br /> the lolal cost of Ihe installation is greater lhan the rebate. � <br /> 7. I, Ihe Vendor, am a l�'ashington State licensed contractor. � ; <br /> 3. The City o([verett v�nll send a Federal Form 1099��115C lo me, Ihe Vendor,for 8ackwater <br /> Prevenl�on Device rebate payments totaling more than SG00 per calendar year, and will <br /> icport the sarne payments to the Internal Revenue Service. ! <br /> II au;epl Ihe payment ol the 13ackwater Prevenlion Device rebate from the Cily of Everett pending � <br /> i ;�pnro��al oF thr,r.nmpleled[3ackwaler Provenlion Device rebate package by Ihe Clty of Everett I <br /> I I <br /> � � <br /> I �------- � <br /> �1����s" � <br /> � S�gnalurc o(Contraclor Dalc ! <br /> , <br /> I - —_ _ --- - -- — -- _ _ _ _ I; <br /> i <br /> I <br /> I <br /> , � <br /> I <br />