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Contractor Section: <br />�^iC.�k�--�'�cc� j�_ca�. `�F'�c��('1 LLC; <br />Vendor Name I Busine s Name 1 UBI Numher <br />•c�'� ��_��3 <br />: _�`_ri�-�.Z�� 5 � %1_��-- - - - -- <br />State of Washington Contractor License Number. <br />���� L--_Q r_1; �1—D_P_,—� N_� �_it _ I,�� �' �:�o_� <br />Vendor I�13iling Address City State Zip <br />lac� �1o_�g.�C��r_�dt_cic,�.�?��. �>�i ��l� ��Q��orr_1 <br />Phone Email <br />I, ihe Vendor, agree to rer,eive the Back�vater Prevenlion Devic� rebale check direGly for �he <br />installalion at the above re(erenced property address. By agreaing to receive Ihe rebate check <br />directly, I agree to the following� <br />1. The Backwater PreveM�on Devir,e rebate amount will be deducted from the (inal invoice <br />given to the property owner for lhe installation at lhe property address referenced above, if <br />lh� total c.osl of ihe installation is grealer than �he rebale. <br />2 I, the Uendor, am a Washinglon Stale lir,ensed c:ontractor. <br />3. The City of [verett will send a Federal Form 1099 MISC lo me, Ihe Vendor, for Backwator <br />I�revention Device rebate payments tolaling more lhan 5600 per r.alendar year, and �vill <br />reporl the same payments to lhe Inlem�i Revenue Service <br />I acc:ept the payment of Oie Backwaler Preven6on Device rebale fmm Ihe Cily o( Everelt pending <br />approval of the compleled Bac.kwater Prevenlion Devir,e rel�ate peckage by the Ci1y of Everetl <br />��� l��t � �Ci—.'�—�..� - ----- - - --- �i"j `� � - — � -- <br />r.�----- - <br />Signature of Contractor Date <br />