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i <br /> I <br /> Contractor Section: <br /> f'�� `��,' 1��.'- �G-�-�� '• ��t'-�--i�'—l; LLG >c�?� :3�%�i-�3� � <br /> Vendo�1 fiusine s Name/UBI Number • ` <br /> �i_�'�L��_._5`�--:�-', 14.�_—_ <br /> Stale of Washinglon Contractor License Number. <br /> �21P�1_(�____L_t�r�i_�1�(�,�-F��C��1� �.7�- rt��- <br /> Vendor Mailing Address City State Z�P <br /> ,a[`In-���n�►�Qa C•�d�c�i �� � : �,��►�1��. �Gr�_- � <br /> Phone Email � <br /> I, the Vendor,agree lo receive the Backv�ater Prevention Device rebate check directly ior the <br /> rs!allation at lhe above referenced property address.By agreeing lo receiveihe rebate check <br /> d rectly, I agree t0 the following: <br /> 1. The Back��ater Prevention Device rebale amount will be Aeducled from lhe final invoice <br /> given to lhe property owner for the installation al lhe property address referenced above,if <br /> the tolal cost of lhe installation is greater than ihe rehate. <br /> 2. I, lhe Vendor, am a Washington State licensed contractor. <br /> 3. The City of Everett v+ill send a Federal Form 1099 MISC 10 me,the Vendor, tor Dackwaler <br /> Prevention�ovice rebale paymenls totaling more than 3600 per oalendar year,and will ; <br /> report tho same paymenls to the Inlemal Revenuc Service. , <br /> I acr.e 11he paY�nenl oF Ihe Backwaler Prevention Device rebale from tho Ciry of Everett pending � <br /> P <br /> approval o(the compl�ted Backwater Prevention De�ice rebate pa�kage by tl�r.City ot Cverett i <br /> I <br /> � <br /> � <br /> � <br /> �/ //�/ �/1 r �/� � <br /> •G�- � V-3' �Y-�: �- • <br /> Signature of Contraotor Oate <br /> , <br />