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Contractor Section: <br />/�r'�il.�.0 i�Gu.r►qiZ�.�/rr lx�.>' —o/>' —vs51 <br />Vendor Name I Business Name ! UBI Number <br />7 f•' L F'!. S�G � L�>' --- <br />5tate of Washington Contractor License Number: <br />.s `iG% �7/j r/�V � /I/j:. M/iJi 5�.5 ✓1f1L �N/} 9�S ��„ %C� <br />Vendor Mailing Address City State �ip <br />�� � J-1,���' - <br />Phone ' Email <br />I, the Vendor, agree to receive lhe Back�a�aler Prevention Device rebate check directly for the <br />inslallalion at the above referenced property address. By agreeing lo receive ihe rebate check <br />directly, I agree to the tollo�ving: <br />1. The Backeaater Prevenlion Uevice rebate amouni �vill be deducted from the final invoice <br />given to the propeity om�ner for the installation at tiie property address referenced above, if <br />the total cost of lhe installatlon is areater than P ie rebate. <br />2. I, the Vendor, am a Washington Stale licensed contractor. <br />3. The Ciry of Everett �vill send a Federal Form 1099 MISC to me, the Vendor, for Backwal�r <br />Prevention Device rebate payments totalinc� m�re than $G00 per calendar year, and �vill <br />report the same payments to Ihe Inlernal Revenue Service. <br />i accept ihe payment ot the [iackwaler Prevention Device rebate from lhe City of Everelt pendine� <br />approval of the compleled Backwater Prevenlion Device rebate package by the Ciry of Everett <br />.. �o- (2-1� <br />Signature of Contrector __. , ' Dale <br />