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Contractor Sectior: <br />,��s�l.�-��5������,.� ���-����s= il'�_ � <br />Vendor Name / Business Name 1 UBI Numb r <br />f�i�So�S$ g�.1 � 5 - --- ---- - <br />Staie of VVashington Uo ctor License Numbec <br />���� ����� 5-�._S �. �" � cv�_ R�o� � I <br />Vendor tvlailing Address City State Zip <br />a�._�6� r_��y� f'7t�Sa�w7eS�Se�e2��cu( � <br />Phone Email <br />I, the V_ndor, agree to rec�ive lhe Backwater Prevention Device rebate check directly for the <br />installalior. at the a6ove referenced property address. By agreeing fo receive lhe rebale check <br />directly, I agree to the following: <br />1. The Bac4water Prevention Device reb„�., amounl will be deducted from the fnal invoice <br />given to lhc property owner for the installalion al the property address refere�iced above, if <br />lhe tolal cost of Ihe installation is greater lhan the rebate. <br />2. I, lhe Vendor, am a Washington Slale licensed contractor <br />,. The City of Everztt will send a Federal Form 1099 MISC to me, Ihe Vendor, for Back�vater <br />Prevention Device rebate paymenls tolaling more than 5600 per calendar year, and will <br />report Ihe same paymenls to lhe Internal Revenue Service. <br />I accept the payment o� �he Backwaler Prevention Device reb2te (rom lhe City ot Everelt pendinr� <br />approval oi the completed Backwater Prevention Device rebate package by Ihe City of Everett <br />� , ����� _ I_� � ��aol� <br />Sig tur . Contractor Dale <br />