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i <br /> � <br /> i <br /> i <br /> � <br /> � <br /> i <br /> Contractor Section: <br /> -- � <br /> �''� �`c'.n l�I��h ��, r� GO � vSj�l �j�l;;� 1 <br /> Vendor Name/Business Na��e/UBI Number ; <br /> � <br /> I <br /> _ M �e.n PI'� S;�k ; J'�, ; <br /> State of Washington Contractor License Number: � <br /> i <br /> 17S 15 �!(=r SF. SE <7��oi�� t�� l,/�4 ��5�7_�iU � <br /> Vendor Mailing Address City State Zip t <br /> `I � s 7L-O y�C•C '1 te��� �J r�i u�.� ����„-�lj���y. ccu� ` <br /> Phone Emai! i <br /> � <br /> I,the Vendor, agree to receive the Back�vater Prevention Device rebate check directly for lhe ! <br /> installation at the abnve referenced proporty address. By agreeing tu receive the rebate check i <br /> directly, 1 agree lo the following: � <br /> � <br /> 1. The Baokwater Prevei�ilon Device rebate amount will be deducted from the final invoice j <br /> given lo the property owner for ihe installation at the property address referenced above, if � <br /> the total cost of the installation is greater than the rebate. � <br /> i <br /> 2. I, lhe Vendor, am a lNashington State licensed coniractor. f <br /> i <br /> 3. Thc City oi Everett will send a Federal F�rm 1099 MISC to me,the Vendor, for Backwater ; <br /> Prevention Device rebate payments totaling more thar �600 per calendar year, and wiil ! <br /> report the same payments to the Intemal Revenue Service. <br /> i <br /> -- — i <br /> i <br /> I accept the payment of the Backwater Prevention Device rebate from the Cily of Everett pending � <br /> approval of tho completed Backwaler Prevenlion Device rebale package by the Clry of Everatt ! <br /> ; <br /> I <br /> G � <br /> �l2ri✓7 �J /�7�r_-__ s—l� - ( � I <br /> � <br /> Signature of Contractor Date � <br /> _ � <br /> � , <br /> i <br /> i <br /> i <br /> i <br /> I <br /> i <br /> ,i <br />