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Contractor Section: <br />Vendor Name 1 Busine�s Name I UBI Number <br />�/ 1�-�;L.��-?jirz_Li � -- -- <br />State of Washington Contractor License Number: <br />�3(��� !-Gt.�I�i.�1_�_P>,--��' J -.'�-_t �r �i'�'�G.:� <br />Vendof Mailing Address City Stale Zip <br />� -�n�ang�C�� ��_r�s:�._�a. �,�.�h����r�'� _ <br />Phone [mail <br />I, the Vendor, ac�ree to receive the Backwater Prevention Device rebate check directly for the <br />installation at the above referenced property address. By agreeing to receive the rebale check <br />directly, I agree to the (ollowing� <br />1. The �ackwater Prevention Device rebale amount will be deducted from the flnal invoice <br />given to the property owner for lhe insfallalion at the property address referenced above, if <br />the tolal cost of Ihe installation is �reater than the rebate. <br />2. 1, the Vendor, am a Washingion State licensed contractor. <br />3. The City of Fverett will send a Federal Form 1099 A�ISC to me, the Vendor, for Backv;aler <br />Prevenlion Device rebate payments totaling more than 3600 per �alendar year, and v�ill <br />report the same payments to the IMerna� Revenue Service. <br />� <br />I accept Ihe paymenl of the Back�vater Prevention Device rebate irom Ihe City of Everelt pending <br />approval of the completed Ba�kwater PrPvention Device rebale package Uy tha City ot f=verett <br />���� � �'�� -�-(.��I.� - <br />Signature of Conlrac[or Date <br />