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Contractor 5ection: <br /> � '`�5��U��o�rv�aN eu1 S <br /> f <br /> Vendor Name/Business Name/UBI Numbe <br /> .�so�ss 8 1.�� <br /> State of Washington Contractor License Number: <br /> '��f�3 �3�t'' S� SW� f�r,,oN�r l�i�- qgoa� <br /> Vendor Mailing Address City State Zip <br /> aU(7�((�S• ��q� �750���7P�S7�R�'� aN�^SC� 0� l'J�.I�II � �M <br /> Phone Email <br /> I,the Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <br /> installation at the above referenced property ad�'��ss. By agreeing!o receive the rebatn check <br /> directly, I agree to the following: <br /> 1, The Backwater Prevention Device rebate amount will be deducled from the final invoice <br /> given to the property owner for the installation at the property address referenced above, if <br /> the iotal cost oi the installation is grealer Ihan the rebate. <br /> 2. I,the Vendor, am a Washington State licensed contractor. <br /> 3. The City of Everett witl send a Federal Form 7099 MISC to me, lhe Vendor,for Backwaler <br /> Prevention Device rebate payments totaling more than 5600 per calendar year, and will <br /> repoA the same payments to lhe Inlemal Revenue Service. <br /> I accepl the payment of the Backwaler Prevention Device rebate from lhe City oi�veretl pending <br /> approval of the compleled Backwaler Prevention Device rebale package by!he City ot Everett <br /> � <br /> I,�„ �a- ��- a�ry <br /> ignature of Contractor Dale <br />