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Contractor Section: <br />Mven I���r•�� <br />Vendor Name / Business Wame / UBI Number <br />�3 -Kb'�- s��� <br />M ��e/� Y P��� 3"s p <br />State of Washington Contrector! icense Number: <br />17S"�s �-(rsY sd- SC Sn���r,�iG. t,✓�' G�z-�v _ <br />Vendor Mailing Address City State Zip <br />�-/ �. S~ -7(, U <br />Phone <br />Email <br />I, the Vendor, agree to receive ihe Backwater Prevention Device rebate check directly for the <br />installation al the above referenced property address. By agreeing to receive Ihe rebate check <br />direcily, I agree to the following� <br />1. The Backwater Prevenlion 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 cosl of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington Stale licensed contractor. <br />3. The Cily of Everett will send a FeAeral Form 1099 MISC to me, the Vendor, for Backwater <br />Prevenlion Device rebate payments totaling more than $600 per calendar year, and will <br />report Ihe same payments to the Internal Revenue Service. <br />I accepf Ihe payment of Ihe �ackwater Prevenlion Device rebate (rom ihe City of Everelt pending <br />approval of Bie completed f3ackwater Prevention Device rebate package by the City ot Everett <br />�� � %r�--- 5�= l� -� r <br />SignaWre of Conlraclor Date <br />I�— - --- - — -------- .- — -- <br />