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Contractor Section: <br />i919-�(�mbh��L (�Z- "7� z =783 <br />Vendor Name 1 Business me / UBI Number <br />� P� P�uL �c- D�/ P/� <br />State oi Washington Contracbr License Number. <br />��� ucs�zc va.�v� l9�E {Q,.u-� .�, �� `��'� o� <br />Vendor Malling Address City Slale Zip <br />phone <br />_ ��89- alZ3 �-,�l��l�r <br />Email <br />I, lhe Vendor, agree to receive the 8ackwaler Prevention Devlce rebale check directly tor 1he <br />installalion at the above referenced property address. By agreeing to reccive Rie rebale check <br />directly, I agree lo the followm� <br />1. The Backwaler Prevenbon Device rebate amount �vill be deducted (rom the Gnal invaice <br />given to the property o�vner for the mstallation at the property address referenced above, if <br />ihe tolal cosl of the inslallation is greater lhan lhe rebate. <br />2. I, the Vendor, am a Washinglon Slate licensed contractor. <br />3 The City o( Evemtl will send a Federal Form 1099 MISC lo me, the Vendor, for Backwater <br />Prevention Device rebat� oaymenls totaling more Ihan $600�per calendar year, and will <br />report the same paymenls 10 the Intemal Revenue Service. <br />I accepl Ihe payment of lhe Backwater Prevention Device rebale from the City o( Eveielt pending <br />approval of the compleled Backwater Prevenlion Device rebate package by the City of Everett <br />J �—����K��__ . <br />� <br />Signature of Contraclor <br />'�jr-/%�% <br />Date <br />