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Contractor Se�t�or: <br />���.��a i'l, ,,•�B;.�r __ _G--o� <JJ3 <br />Vendor Name ! Business Name ! UBI Number <br />A�a�__t_'� f�-3_.�i _ <br />Staie of Washmgton Conlractor License Number <br />JS <br />-S�/G7 %� f}�/v NF r-rv/y'S v� i/G w/� ._ �� 7fJ <br />Vendor Mailing Address City Stale Zip <br />Phone <br />Email <br />I, lhe Vendor, agree lo receive the Backwater Prevention Device rebale check directly for lhe <br />ins�allation at the abovo referenced property address. By agreeiny to receive the rebate check <br />direcUy, I agree lo lhe following: <br />1 <br />2 <br />3 <br />—.� <br />The Backv�ater Preven6on Device rebale amount �vill be deducled from the final invoice <br />given to the propert;- owner for the installation at the property address referenced above, if <br />lhe total cost of the mstall.�tlnn is greater lhan the rebate. <br />, the Vendor, am a Washinyton Slale licensed contraclor. <br />� he Cily of E�• arett v�ill send � Federal Form 1099 MISC to me, the Vendor, (or E3ackwa(er <br />Prevenlion Dewce rebate paymenls tolaliny mo�e ihan 5600 per calendar year, and will <br />report Ihc same payments lo Ihe Internal Revenue Service. <br />I accepl the pay; �nl of !he Backwaler Prevention Device reba�e from lhe City of Everelt pending l <br />approval of the ci �leled Backwaler Prevention Device rebate packa�e by the Ciry of Everett <br />� II <br />���/ / _ . <br />- /�. .- - -- --- - �/23/ir <br />Signalure of Conlracic� Dale <br />