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J1,t;nk'rR- <br />Vendor Name / Business Name / UBI Number <br />Iss g'�-1S 5 <br />State of Washington Contractor License Number. <br />Vendor Maiiing Address <br />�i��� �'I��- W �' <br />Phone <br />n City <br />I"�b.S'ol K�-`, <br />Email <br />�' S - ,%�i� - � �'�- <br />�-��-. G���� <br />State Zip <br />a��\ ������'�ua.� I , c.�r� <br />I, the Vendor, agree to receive the Backwater Prevenlion Device rebate check direclly for the <br />installatfon at the above referenced property address. By agreeing to receive Ihe rebate check <br />directly, I agree to the following: <br />1. The Backwater Prevention Device rebate artiount will be deducted ftom the final invoice <br />given to lhe property owner for the i�slallation at the property address referenced above, if <br />the totai cost of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington Slate licensed contractor. <br />3. The City oT Everett will send a Federal Fortn 1099 MISC to me, lhe Vendor, for Backwater <br />Prevention Device rebate payments totaling more than $600 per calendar year, and will <br />report the same payments to ihe Internal Revenue Service. <br />I accept the payment of ihe Backwater PrevenUon Device rebate from the City of Everett pending <br />approval oF the completed Backwater Prevention Device rebate package by thtj : ity of Everett <br />��v��.��.� <br />�Signature of Conlraclor j � <br />i�l� ���1�-! <br />Date , <br />