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i <br /> � <br /> I <br /> ; <br /> Contractor Section: i <br /> �lo�,-. PI� .�� �� � U � G �'� � L i <br /> , 1 <br /> Vendor Name 1 Business Name UBI Number � <br /> Moen PP %►` �8 3.TO � <br /> State of V�'�shington Contractor License Number: <br /> � �SiS �� i � s1 Sl= S 1 ' <br /> ,�� ,��,�sti W� ��a�,� <br /> Vendor Mailing Address City State Zip � <br /> � '�l�s 7i�v Ss3 �U '(r<�f � i�uer1 .01uin�ai��t� , cv.� � <br /> IPhone tmail — , <br /> I,the Vendor, agree to receive lhe Backwater Prevention Devi�e rebate check direclly(or tha ; <br /> installation at the above re(erenced property address. By agreeing to receive the rebate check � <br /> direcliy, I agree to the follo�ving: ' <br /> i <br /> 1. The Backtivater Prevention Device rebate amount will be deducled frorn the final invoice <br /> given to the property owner tor the installation at the property address referencad above, if ; <br /> Ihe total cost of the installation is greater than the rebate. i <br /> 2. I,Ihe Vendor, am a INashington Stale licensed coniractor. � <br /> 3. The Ciry oF Everett will send a Federal Form 1099 MISC to me, the Vendor, for Back�valer I <br /> Prevention Device rebafe payments totaling more than�600 per calendar year, and�+�ill � <br /> report the same payments to the Internal Revenue Service. <br /> i <br /> � � <br /> I accept the payment of the Backwater Prevention Device rebate from Ihe City of Everett pending i <br /> approval of the completed B2ckwaler Prevention pevice rebate par.kac�e by Ihe City of Everett <br /> I <br /> � <br /> ";/'G'_.1 0 1 `j`lZe.e.�- �-('o��'-I� <br /> Signature of Contractor Date � <br /> i <br /> i <br /> � <br /> ; <br /> � <br /> . � <br />