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i <br /> ; <br /> i <br /> Contractor Section: i <br /> � <br /> I <br /> � � <br /> �f.�l,�� fLuM j �itiv l�.>' —G% � — GS� <br /> Vendor Name I Business Name/ UBI Number � <br /> ! /��s-��'L 57�� [L I � <br /> State of Washington Contractor License Number. j <br /> s�� �ij'',�v� NG M/�12vs✓<i�; tw�t Q��;�� � <br /> Vendor Mailing Address Cily State Zip � <br /> � (`l�t) 5�s7 '�1���7 <br /> � Phone ' Email <br /> i j <br /> I, the Vendor, agree to receive the Backvrater Prevention Device rebate check direcUy for the ; <br /> installation at the above referenced property address. By agrzeing to receive ths rebate check � <br /> directry, 1 aorze to the following: � <br /> 1. Tho Backwater Prevention Device rebaie amount will be deducted from ihe final invoice � <br /> given to the property owner for the installalion at the property address referenced above, If <br /> the total cost of th= installation Is oreater than the rebate. ! <br /> 2. I, the Ver�dor, am a Washington State licensed centractor. i <br /> 3. The City of Everett v�ill send a Fe�eral Form 1099 MISC to me, the Vendor, for Backwater i <br /> Prevention Device rehale peS�menis totaiing mcre than SG00 per calendar yaar, and�vill <br /> report iha same payments lo lhe internal Revenue Setvice. j <br /> i <br /> I accept the payment of the Backwater Prevention Device rebate from iho Cliy oi Everelt pending <br /> approval of the completed Back�vater Preven;ion Device rebata package by the Ciry of Everett � <br /> I <br /> , <br /> 5= � <br /> �1-�.�-r s <br /> Signature of Contrector Date ; <br /> i <br /> i <br /> • � <br /> � <br /> � <br /> 1 <br /> � • � <br /> i <br /> i <br /> i <br /> { <br /> i <br />