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Contractor Sectio n: <br />Vendor Name ! Buslness i�Tame i UBI Numher <br />�'s_�G�PG�4�s%,l- <br />Slate of Washington Contractor License Number. <br />.Sya% J�''AUG ,/,/fp MG.�^1SV)//G 'WA ,� 7�. rJ <br />Vendor Mailing Address City 5late Zip <br />Phone Email <br />I, ihe Vendor, eg�e9 lo receivtt Iho Backwater Prevention Device rebate check directly for the <br />instaliation at the above referenced properly address. By agreeing to receive Ihe rebate check <br />direclty, I a�ree to lhe (ollo�ving: <br />1. The Backvraler Prevenlion Device rebate amount will be deducted from lhe linal imoice <br />given lo the propeny owner for lhe installation at the propeKy address refQre�ced above,'if <br />Iho total cosl of the installation is greater than tho rebate. <br />2. I, Ihe Vendor, am a Washington Slale IiCCnsetl Conlraclor. <br />3. 7he Cily oi Everell �wll send n Federal Form 1099 fv11SC 2o me, the Vendor, for Backwatcr <br />Prevention Device rebate payments lotaling more lhan g600 per calendar year, and wiq <br />report the same paymenls to the Internal Revenue Service. <br />I accept the paymenl of tho t3ackwater Prevention Devi�e rebafe from 1he Clty ot Everetl pend(ng <br />approval of iho completed Backwaler Prevention Dovice rebale package by the City of Everett <br />5�gnature of Contraclor <br />3l9/�s' <br />Oate <br />