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Contractor Section: <br />AL5A�k SUM kyta Sewer (�3 - ass 11 q- <br />Vendor Name I Business Name I UBI Number <br />4-5015 7j"\ s <br />State of Washington Con ractor License Number: <br />��Ok Sf' S,W. 6c ,Va4 -VJ4 f 6P(�' <br />Vendor Mailing Address /j City State Zip <br />Phone Email <br />1, the Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <br />installation at the above referenced property address. By agreeing to receive the rebate check <br />directly, I agree to the following: <br />1. The Backwater Prevention Device rebate amount will be deducted from the final invoice <br />given to the property owner for the installation at the property address referenced above, if <br />the total cost of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. The City of Everett will send a Federal Form 1099 MISC tome, the Vendor, for Backwater <br />Prevention Device rebate payments totaling more than S600 per calendar year, and will <br />report the same payments to the Internal Revenue Service. <br />I accept the payment of the Backwater Prevention Device rebate from the City of Everett pending <br />approval of the completed Backwater Prevention Device rebate package by the City of Everett <br />o&8'a rkg-�-- D- D S <br />Sig tune)i Contractor Dale <br />