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Contractor Sectlon: <br />�/- I LZl1 I�ILiM/7�11c� �7 �� V' O l �L�� <br />Vendor Name / Busines� Name UBI Number <br />M�en PP-� ��3.To <br />State of Washington Contractor License Number. <br />I7515 �I�u Si S_r- Sn��ur��'r% �^'j} l'I�o�CiU <br />Vendor Mailing Address City State Zip <br />wzs �bv � <br />Phone <br />Email <br />�LUN� <br />I, the Vendor, agree to reoeive the Backwater Prevention Device rebate check directly for the <br />fnstallatlon at the above referenced property address. By agreeing to receNe the rebate check <br />directly, I agree to lhe following: <br />1. The Backwater PreveMion Device �9bate amount will be deducted from the final Invoice <br />gtven to the properry owner for the installation at the'property address referenced above, if <br />the totel 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 ma, the Vendor, for Badcwater <br />Prevention Device rebete payments totaling more than $600 per calendar year, and wiil <br />report the same payments lo the intemal Revenue ServiCe. <br />I accept the payment of the Backwater Prevention Device rebate from the Cily of Everett pending <br />approval of the rnmpleted Backwater Preventlon Devica rebate package by the City of Evereq <br />�'-� °� �� <br />Signature o( Contractor <br />� <br />i�- i�-�y <br />Date <br />