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Contractor Section: <br />/i/�iu//U %�/G.n /�: n 4 (Xi.3 G)� GSU —. _I <br />_O <br />J <br />Vendor Name I Business Name ! UDI Number <br />f��i/���_y�3GT _ <br />State of Washington CoMractor License Number. <br />S�/G7 %I fy A✓C Ni= M<s��S ✓� ��G v�' f� Z7G <br />V2ndor iviailing Address • City State Zip <br />(/zs 3�7- �� <br />Phone Email <br />I, Ihe Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <br />installation at the above reterenced property address. By agreeing to receive the rebate check <br />direclty, I agree lo the lollovnng� <br />1. The Backwater Prevention Device rebale amount will be deducted from the final invo�ce <br />given to the property o�n�ner for ihe installation al the property address referenced above, d <br />the tolal cost of ihe installation �s grealer Ihan lhe rebate. <br />2. I, Ihe Vendor, am a 1Nashmgton State licensed conlractor. <br />3 The City of Everetl wlll send a Federal Form 1099 h11SC to me, the Vendor, tor Backwater <br />Prevention Device rebate payments totaling more tiian 5600 per calendar year, and will <br />report the same payments to the Intemal Revenue Service. <br />I accept lhe payment of the Backwater Prevention Device rebate from the City ol Everetl pending I <br />approval of the compleled Backwater Prevention Device rebate package by the City ol Everett i <br />SignaWre ol Contractor <br />i/G/z��� <br />Date <br />