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� <br /> Contractor Section: <br /> �'�`� f�t U✓Vl �o i 12� L(..L , Cy�S �l�.i . . �Z'1 i z -"��i� I <br /> -r— - -- <br /> Vendor Name I Busine Name I UBI Number <br /> -��-j�i4-f'I u�p , I P r� , <br /> State of Washinc�ton Contractor License Number: <br /> —� Gf V c5 f' __ 't�lsur�-� W� ��Q 8 <br /> Vendnr R�ailing Address Ciiy State Zip <br /> ��-5�-��O1Z�3 _ u�.�10( ���"1 `�—e-rnAi � � <br /> Phone Email <br /> I, the Vendor, agree to receive the Backe�aler Prevention Device rebale check direGly for Ihe <br /> installation at the above referenced property address. By agreeing to recoive the rebate check <br /> directly, I agree to lhe following� <br /> 1. The 8ackwaler Prevenhon Device rebate amount will be deducted from lhe (inal mvoice <br /> given to lhe property owner lor the installation al the property address relerenced above, il <br /> the tolal cost of Ihe installalion is greater than the reba+e. <br /> 2. I, the Vendor, am a Washington Stale licensed contraclor <br /> 3. 7he City of Everelt wlll send a Federal Form 1099 MISC to me, ihe Ventlor, /c,r Backwaler <br /> PrevenGon Device:ebate payments tolaling more than 5600 per catendar year,and will <br /> reporl lhe same payments to the Inlemal Revenue Service. <br /> ( 1 accept Ihe payment of the Backwater Prevention Device rebale from lhe Cily of Everelt pending <br /> approval of Ihe comple�ed Backwater Prevention Device rebale pack.�ge by Ihe City of Everett <br /> �1�`'�" -�_3-�5�_ <br /> Signature of Coniractor Dale � <br /> I I <br />