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Contractor Section: <br />M cc�/-N 121tA &% be, % <br />G 0 a <br />4-1 L <br />Vendor Name / Business Na <br />e / UBI Number <br />Mvts PPS ssu _3 <br />To <br />State of Washington Contractor License Number: <br />17S 15 t.f(1� Jf. 4 r <br />S,1dn Ui'11 t� <br />i , <br />WA 61Jp 790 <br />Vendor Mailing Address <br />City <br />State Zip <br />Lj1 , S• 7G U y?L.o <br />Iren460 ILA Oe-A9LI'"i)Ir <br />ita cork <br />Phone <br />Email <br />I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <br />installation at the above referenced property address. By agreeing to receive the rebate check <br />directly, I agree to the following: <br />1. The Backwater Prevention Device rebate amount will be deducted from the final invoice <br />given to the property owner for the installation at the property address referenced above, if <br />the total cost of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br />Prevention Device rebate payments totaling more than $600 per calendar year, and will <br />report the same payments to the Internal Revenue Service. <br />I accept the payment of the Backwater Prevention Device rebate from the City of Everett pending <br />approval of the completed Backwater Prevention Device rebate package by the City of Everett <br />Signature of Contractor Date <br />