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Contractor Section: <br />- 5�;�� i"D_��_ �5� __i�L� <br />Vendor Name ! Busine�s Name / U81 Number ! <br />-�-'J�11�� � �' /��_— — -- --- — i <br />Siate of Washirgl�n Co»traclor License Numbec � <br />� 0 , ��( � r _ _ —�1/�_%��� - �,1��_ _ �` � �5 i <br />Vendor Liailing Address City State lio <br />�1.2�'_��1�' 3�16b _ �P�. _ <br />Phone -mail ' <br />I, thc Vendor, agree to receive the Back�vater Prevention Device re6atc check direclly tor the <br />nslallation at the abovo referenced properly address. By agreeing lo receive the rebale check <br />d�rectly, I agrec to Ihz `ollowinq: <br />t The Backclaier Prevemion Device rebate amount e�ill be deducled from the linal invoice <br />given to the property owner tor the installation al ihe properry address relerenced a�ove, il <br />the total cost of the installa�ion is greater than the rebate. <br />; I, the Ver,dor, am a Washington State licensed contractor. <br />3 The City o( Everett will send a Federal Form 1099 tv11SC to mc, the Vendor, (or �ackvealcr <br />I�ICVCfI�IOfI DP.\9CP, fChale paymen�s totalint� more than $60� per caiendar year, and e^nll <br />report the ,ame payments to the Internal Revenuc Service. <br />; I accept ihe payment ol tiie Backwater Prevenlion Device rebate iroin the Cuy af Everett pendinr� � <br />approval of Ihe completed [3ackwater Prevention Device rebate packac�e by the Gty ot Everett <br />- ,ti2 -Zs�ls <br />�a« <br />