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� <br /> � <br /> , <br /> ; <br /> i <br /> i <br /> Contractor Section: � <br /> r— � <br /> , ��,.,� �,�� � <br /> �ic�t1—` ' ��s.�e����cc�!`ru—�-____��_� ; <br /> Vendor Name I Busine�s�x�Na e/�UBI Number i <br /> ����I-..J�- Y7-�-, �� —--- � <br /> State of Washington Contractor License Number: ; <br /> �(t�D�L�C��i�1—Q.F,:_—�1✓Nl.P_-'�"_I,�r����l;� ; <br /> Vendor Mailing Address City State Zip <br /> � <br /> �cz4,_ :�Ln=�t�s�_C?t����c�a�� �• yrzJ�o��[��h_2__ ' <br /> Phone Email <br /> I, ihe Vendor,agree to receive the Backwater Prevenlion Device rebate check direclly for the <br /> installation at the above referenced property address.By agreeing fo receive the rebate check <br /> direclly, I agree lo the followin�: <br /> 1. The f3ackwater Prevention Device rebale amount will be deducled from the final invoice <br /> given to the property owner for Iho inslailalion at the property address roferenced above, if ' <br /> ihe total cosl of Ihe inslallation is�reater than the rehat�. <br /> 2. I, lho Vendur, am a Washington Stale licensod contracloc � <br /> 3. The City o([verolt will send a Foderal form 1099 MISC lo me,the Vendor,for Bockwat�r , <br /> prevcnlion Devicc rebalc payments totalin� moro Ihan 5600 per calendar year,and wili <br /> repori the samr.paymenis to Ihe Inlernal Revenue Scrvice. <br /> f <br /> _._-_.__ �__ __ _ _- _-__ .__ _ -_-_ i <br /> I accepl the payment of�he Backwaler Prevenlion Dr.vica rebate from Ihe City of Everelt pandin� <br /> approval o(the completed Backwater Prevenlion Devir.e r?bale package hy Ihe City of Everetl <br /> I <br /> � <br /> ��- � �,�'__---- �LK��`= - � I <br /> Signalure of Contractor Dale � � <br /> --- _— _- - --- - - -- -- -- — -- - ' I <br /> i <br /> I <br /> i <br /> i <br />