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i <br /> ; <br /> � <br /> � <br /> � <br /> Contractor Section: . � <br /> t�Y1�{`'�Plkl-'�1,— ,� "�..`•,�L_[�_,_�i ' �t. ' � LLc:. l>t.%'> ;3�i'�::�3 i <br /> Vendor Name! Busine.s Name/ UBI Number � <br /> i <br /> f <br /> � � i <br /> QNk , r < —���i�4 -- _ ; <br /> Sta[e ol Washington Contraclor License Number. <br /> ��� �---c�c1i�''1_E��=---�-N�re������t"�:��.3 <br /> Vendor �4ailing Address City Slate Z�P <br /> �c�-��g�—C��,r����t:_.a:�:.�_ �;�� ��.c_��2._ � <br /> Phone Email � <br /> � <br /> � <br /> I, lhe Vendor,agree to receive the [3ackwater Prevention Device rebate check direcUy for the , <br /> installation at the a6ove reFerenced property address. By agreeing lo receive the rebaie check <br /> directly, I agree to lhe tollowing: . <br /> 1. The Backwater Prevention Device rebate amount will he deducted trom lhe final invoice <br /> given to the property owner for the installation at the property address referenced above, it i <br /> lhe total cosl of thc installation is greater than Ihe reBate ! <br /> 2. I, lhe Vendor, am a Washington State liconsed cnntractor. � <br /> 3. The Cily ot Fveretl will send a Pederal Form 1099 MISC to me,the Vendor, for�ackwaler <br /> Prevenlion Device rebaie payments totaling more than$600 per calendar yrar, and �vill � <br /> repori llie same payments to ihe Internal Revenue Service. ' <br /> � - <br /> I accept the payment of ihe Backv�ater Prevention Device rebate from Ihe Cily of F..verett pendiny <br /> approval ot Ihe completed Backwater Prevention Device rebale package by Ihe Clly oF Fverelt � <br /> l�%t � t--�=�'_'—'"'/ . —�.L�OZ-`��-- �� <br /> �-- <br /> Signalure oi Coniractor Dale <br /> I - — - - - - - '. <br /> � - -- -- -- � <br />