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Contractor Section: <br /> �� fo//G iJ�U.�I a:�� �- - (��i�CfJ�� G.S� � <br /> Vendor Name / Business'IOame / UBI Number i <br /> I I <br /> i __�c.�/� .�3 �� _. <br /> State of VJashington Contractor License Number. �I <br /> S+' I <br /> I 'S�j��? -�/ f�� N_,—:� /'�1csTy5 ';L 1 iE 1.v/Y—J��7c� � <br /> I Vendor h4ailing Address City State Zip i <br /> I ��ZS� 5��— ( S07 I <br /> Phone Email I <br /> �— - — — I <br /> I, ihe Vendor, agree to receive the Backwater Prevention Device rebate check direcUy for the <br /> installa6on at the above referenced property address. By agreeing lo receive lhe rebate check <br /> directly, I agree lo the following: <br /> 1. The Backviater PrevenGon Device rebate amount will be deducted from the final invoicn. <br /> given to ihe property owner for the installalion at the properly address referenced above, if <br /> the total cost of the.installation is greater than the rebale. <br /> 2. I, the Vendor, am a Washingron State licensed contracior. <br /> 3 The Cily of Everelt v�ill send a Federal Form �099 MISC to me, tne Vendor, for 9ar.ki•�ater <br /> Prevention Device rebate paymenls totaling more than 5600 per calandar year. and �vill <br /> report the s2me payments to the Internal Revenue Seriice <br /> ( I accept the payment o(the Backavater Prevention Device rebate from the City o( Everett pendiny <br /> approval o(ihe completed E3ackwater Prevention Device rebate package by lhe City of Everelt <br /> � i <br /> _ / 23 /S <br /> Signature of Contraclor Da�e � <br /> -- -1 <br />