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' <br /> Contractor Section: <br /> /�%�GI/U -�[1'�2�r CY�.__G1]� GS,�i' <br /> Vendo� Name I Business Name I UBI Number <br /> � ._.�r,// i�/_ 5���3�� <br /> S'ate of Washington Contractor License Number. <br /> S �/o7 7/�` /�✓e �/i% MarvSv�/iG �,,v/�' �7d <br /> � Vendor Mailing Address City State Zip <br /> I <br /> II <br /> �/l ',) 357— I So7 <br /> Phone Emall � <br /> I <br /> i � <br /> '- -- <br /> I, the Vendor, agree to receive the Back�va;er Prevention Device rebate check directly for tf:e <br /> installalion at Ihe above referenced properly address. By agreeing to receive Ihe rebate check <br /> directly, I agree to the fotlowiny: <br /> 1. The Back�valer Prevention Device rebate amount a�ill be deducted from lhe final invoice <br /> given to the property o�vner for the instaltafion at ihe property address referenced above, if <br /> lhe total cost of the installation is grealer than the rebate. <br /> 2. I, the Vendor, am a lNashington State licensed contractor. <br /> 3. The City of Everctt�vill send a Federal Form 1099 �v11SC to me, the Vendor, for Back�^ater <br /> Prevenlion Czvice rebate payments totaling more ihan SG00 pe; calendar year, and c�ill <br /> repn!; ine same payments to the Inlernal Revenue Service. <br /> -- -- — — -- � <br /> I accept the payment of the [3ackwater Prevention Device rebale from the Ciry of Everett pending <br /> approvai of the completed Backwater Prevention Device rebole package by the City of Everett <br /> _.. � �������`/- <br /> Signalure of Contractor Date <br />