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i <br /> t <br /> � <br /> i <br /> I <br /> Contractor Section: I <br /> � <br /> �"� oc'/� I�Ic.in, {�,r� GU ,� (::��9 �i`-/2 � <br /> -- ; I <br /> Vendor Name/Business Na e/UBI Number ; <br /> i <br /> Moe� P('-� s;-u 3 .i�,� ; <br /> State of Washington Conlraclor License Numher: i <br /> i <br /> 175 � $ �Il '—r 5f SC S,�o!-�wti� s� l✓/E �S'7—t) U � <br /> Vendor A4ailing Address Cily Stale Zip • <br /> �� � ti� 7���/ �?��,C) �� fZ.'i7 �V h1 UC:.}l n���.-+�liMcJ. Cc�l+1 ! <br /> Phone Email ; <br /> i <br /> 1 <br /> I, Qie Vendor, agree to receive the Baclnvater Prevention Device rebate check directly for the i <br /> instailation at the above referenced properiy address. By agreeing ro mceive the rebate check <br /> directly, I agree to tho following: j <br /> i <br /> 1. The Back�valer PreveMion Device re6alt�amount will be deducted from the final invoice <br /> given lo Ihe property ovaner for the instaliation at the properly address referenced abova, if j <br /> lhe total cost of ihe installation is greater than the rebate. I <br /> 2. I, the Vendor, am a Washington State ilcensed contractor. I <br /> 3. Tho City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for Dackwater � <br /> Prevention Device rebale payments tot�linc� more than 56D0 per calendar year, and will � <br /> report the same payments lo the Inlernat Revenue Service. I <br /> i <br /> I accept tlie payment of lhe Ba�kwaler Prevenlion Devir.e rebato from ihe City of Everett pondini� � <br /> approval of Ihe completed Backwater Prevenlion Device rebale packege by the Cily of Everett ! <br /> i <br /> � <br /> I <br /> `.'i zw� ''�./i172 c:�-- 3 —f 4 - l S i <br /> � <br /> SignaWre of ConUaclor Dale j <br /> I <br /> — -- i <br /> � <br /> � <br /> i <br /> ; <br /> � <br /> I <br />