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Contractor Section: <br /> !1_'�/b �7�1Qc/��;,n�__G_l.3 osf� . - <br /> Vendor Name/Busfness Name/ UBI Number <br /> ��L '�G�3 Gi • . <br /> Slate o(Washington Contractor License Numbec � <br /> S� if'A�.' Ni� __ .+�,srN'Ysv�%/� �✓�4' _ �xi <br /> Vendor Mailing Address City State Zip <br /> 1 fs7•-i.S77 <br /> Phone Email <br /> I,the Vendor, agree to receive the Backwaler Prevention Device rebate check directly for the <br /> installation al lhe above referenced property address. By agreeing to receive the rebale check <br /> directly. I agree to the folbwing: <br /> 1. The Backwaler Prevention Device rebate amounl will be deducled from the final invoice <br /> given �o the properly owner for the installation at the propert�address referenced above, if <br /> the tolal wst of the installalion is greater than the rebale. <br /> 2. 1, the Vendor, am a Washington State licensed conlractor <br /> 3. The Cily of Everett w�ll send a f"ederal Form 1099 MISC to me, the Vendor, for Backwater <br /> Prevenlion Device rebate payments totaling more lhan $600 per calendar year, anA will <br /> report the same payments lo Ihe Intemal Revenue Service. <br /> I accept lhe payment of the Uackwater Preventlon Device rebate from lhe City of Everett pending <br /> approval of Ihe completed Backwaler Prevention Device n�bate package by lhe City of Everett <br /> lJ f��/(p /�' <br /> L' <br /> Signature of Cnntractor Dale <br /> ._ . , • <br />