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i <br /> ;I <br /> i Contractor Section: <br /> ,'��-�� Pr�„�h;.�� � �� ��� �K2 <br /> , <br /> Vendor Name/Business ame! UBI,Number � <br /> i i <br /> ' /�� ��_� �,Y3�o � <br /> State of Washington Contractor License Number.,. � <br /> ... � <br /> . � �S( S �/I Stsf- SF S.ZJC�un�S�. �-✓�" l,�T�r v I <br /> i <br /> Vendor Mailing Address :City Sfale Zip : � , i <br /> � ! <br /> � ��ZS '7� o �S'1Ga '�rti��'��;<., /'�U..�.r..,�. co,�. i <br /> I Phone � Email ;,�_ . � <br /> �. . . , . . . , . . r ; � . .. •m:i:" � � <br /> I . , <br /> �y i <br /> � <br /> � I,the Vendor,agree to.receive ihe Backwatei Prevenlion;Device rebate check directly.for the ' <br /> instailation.at.the above:referenced property address.'By;agreeing to re�eive the rebate ctieck <br /> directly, 1 ag�ee to the following: • � <br /> 1. The'Backwater Prevention Device,retiate amount will 6e deducted from the final invoice ' <br /> ' " � gi4en�to the properly owner for the installation at Ihe property add�ess referenced above,'if . '" ' � <br /> the total cost of(he installalion is greater than lhe rebate. ' <br /> 2.. I,the Vendor, am a Washington State,licensed contractor. .. <br /> • 1 ��-N <br /> � 3. The:Cityof Everett will send a Fede�al Form 1099 MISC.to me, the Vendor,(or BaCkwater ` <br /> , Prevention Device rebate payments total(ng more ihan 5600 per calendar year, and will '� • � <br /> , report the same payments to ihe Internal Revenue Service. i <br /> I A{•. I <br /> iI accept the payment of the Backwater Prevention Device rebate trom the City ot Everett pending <br /> � approval of the compleled Backwaler Prevenlion Device rebate package by the City of Everett � <br /> � . � <br /> ; � <br /> I ''� /• �.��, i�— • �-( S- ( S� � <br /> i Signature ot Contraclor Date <br /> � <br /> I <br /> � <br /> � • <br /> I � <br /> i <br /> — -- — — � <br />