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i <br /> I <br /> Contractor Section: <br /> ------ --- _ _ -- ---- --- <br /> i r�.i�� iv1���`� 1 N1Ue.v1 PI t,«�1���_�b _C�� �� �, <br /> Vendor Name � Business Name f UBI Number <br /> I /v1 � (�(l��e � 3 .l C� � <br /> IState ot Washington Coniracror License Number. <br /> I �75 r S `ll� S�. Sr Sr.�C�.,;,,,`�,l �.-��- ��Z 4 C� i <br /> Vendor tvlailing Address City State Zip i <br /> y1S 7(�a ��(,o 'rr-v�C� ��� Iw�.,/.,.� . : � � � <br /> 'I Phone Email I <br /> I --- -- --- -- _ __ <br /> I, ihe Vendor, agree to receive the Backtivater Prevention Device rebate check directly for the <br /> installation at the above re(erenced property address. By agreeing to receive the rebate check <br /> direcUy, I agree to lhe (ollowing: <br /> 1. The Backwater Prevention Device rebate amount�vill be deducled from thc final im�cice <br /> given to lhe property owner(or�he installation at lhe property address referenced aGove, d <br /> ihe total cost of the installation is greater than ihe rebate. <br /> 2. I, the Vendor, am a 1Nashington State licensed contractor. <br /> 3. The Ciry of Everelt�vitl send a Federal Form 1099 MISC ro me, the Vendor, for Back�vatcr <br /> Prevenlion Device rebate payments totaling more than 5600 per calendar year, and will <br /> report the same payments to the Internal Revenue Service. <br /> ( I accept the payment of the Backtivaler Prevention Device rebate from ihe City of Everett pending <br /> approval ot lhe completed Backwater Prevention Device rebale package by lhe Ciry of Everett I <br /> � � <br /> �r.,�� ��'�_' � — �7— � S I <br /> Signature of Conlrector Date <br />