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I <br /> i <br /> Contractor Section: ; <br /> i <br /> � ��� � <br /> � <br /> i ��L C>__1�Gu�'1 a ��t/G (� > -cii 3 - v s 5� ; ; <br /> I <br /> Vendor Name/Business Name / UBI Number � <br /> i j <br /> � <br /> .%C_U1.� f'G S�C�� L: � <br /> � <br /> ' Sfate of Washington Contractor License Number. ; <br /> i <br /> � .S %7 '7/s��✓� N.�.__ M/�IZI�SiIiIJ_js` lN/� 9�5�?ic� I ; <br /> iVendor Uailing Address C;ty State Zip I <br /> , ' <br /> i �/ �s��'1�7 i � <br /> i <br /> Phone Email <br /> i <br /> !-- , <br /> i <br /> I, ;he Vendor, agree to receive !iie Back�vat=r Prevention Davice rebate check directiy ior the i <br /> nstailation at the ai,ove referecced property address. By agreeing to receive the rebate check ' <br /> directly, I aaree to tne folfo�vmg: <br /> '. The Back�vater Prevention Device rebate amount�•:ill oe deduc!ed from the tinal irn�oice <br /> gi�ren to the property omner for the instaliation at the property address referenced above, if <br /> the btal cost of the instalfation is grealer tnan the rebata. <br /> 2. I, the Vendor, am a 14�a>hington State licensed contractor. <br /> 3. The City� of Everett �:�ill send a Federal Form 1099 tJ�ISC to me, the Vendor, for Backv,�ater <br /> Pre✓enlion �evice rebate payments totaling more than 5600 per ca'endar yezr, and ��eill ' <br /> report the same paymznts to the Intemal Revenue Service. <br /> I I aco�pt fiie payment of the Backtivater Prevenlion Device rebate from ihe Cily oF Gverett pending � <br /> � approval of the compleled Backwater Prevenlion Device rebale pacicage by th2 City of Everett � <br /> i <br /> � <br /> ��Zs�i S' ! <br /> Signature cf Contrac?or --_. Da,e � <br /> I <br /> -- -- --- ------ i <br />