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i <br /> i <br /> ; <br /> � <br /> Gankrac�a� �ec3iora: ' <br /> i <br /> � � <br /> M e�� I�i � G U � C.>��? ���; ! � <br /> tnrti rr�G ; <br /> Vendor Name/Business Na e/UBI Number I � <br /> I <br /> � <br /> Nlo�n PP� �Ss ��(� I <br /> State of Woshington Coniractor License Number: ° <br /> i <br /> � 7S iS �!j`—' �f SE 5����,u��� s� �✓/E �i�7_`1 U � <br /> i <br /> Vendor Mailing Address City State Zip � <br /> �l �. S� 7L�0 �3( �: ?�-r�n-� L�l ��� c:[:n ,���,�l�i���: cor� __ <br /> Phone Emaii <br /> I <br /> � <br /> � <br /> I,the Vendor, agree to receive the Backv�ater Prevention Device rebate checic directiy tor the <br /> Inst211ation at the above reforencad property address:By agreeing to recelws the rebate check <br /> dlrectly, I agree to the following: <br /> 1. The Backwater Prevention Device rebate amount will be tleducted ftom the flnal invoice <br /> qiven to Uie properiy owner for the instailafion at the properiy address referenced above, if <br /> ihe tolal cost of lho inslailation is greater than fhe rehate. <br /> Z. I,Ihe Vendor, am a Washinglon Slate licensed conlractar. <br /> 3. The Cily of Everolt vaill send a Federal Form 1099 MISC to me,the Vendor,for Bacicwater � <br /> Prevention Device rebate paymenls tolaling more lhan 3600 per c�lendar year,and wfll � <br /> report the same Paymenls to lhe Inlemai Revenue Service. i <br /> -- — — i <br /> i accept 1he payment of iho Backwator Prevention Device rebate from the City of Everett pending <br /> approval of lhu complclyd �i�rMvafnr Prrvention Dovic�rebn�e par,kagH by tha City ot L=verett <br /> ; <br /> 'jJ.�,i7 '',J�%J7�,�>;:� 7_ 1 -1 sr <br /> Slgnoturr-.of Contractor Dale 1 <br /> � <br />