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i <br /> Contractor Section: <br /> � Moe� PI�. ,>, b � n � �� `� 6Ff� `(Na <br /> Vendor Name I Busines�e/UBI Number <br /> I MocnP � * Ss� 33 � . <br /> � State of Washington Contractor License Number: <br /> I �75 I S �-{ I�Sf. 5� Snp�;oris�_ wQ �1 �01�?� � <br /> Vendor Mailing Address ' City State Zip � <br /> � a S 7b0 �3 �� _ I're��'Q Moa� I�..,h� � �-or'"' <br /> Phone Email � <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly (or the I <br /> instailation al the above referenced property address. By agreeing to receive the rebate check <br /> direclly, I agree to the following: ' <br /> 1. The Backwaler Prevention Device rebate amount will be deducled from the (inal invoice <br /> given to the property owner (or the inslallalion at the property address referenced above, if <br /> the lotal cost of the installalion is greater Ihan the rebale. <br /> 2. I, the Vendor, am a Washington State licensed contractor. <br /> 3 The City o(Everelt will send a Federal Form 1099 MISC to me, the Vendor, for Backwatn,r ; <br /> Prevention Device rebate payments totaling more than �600 per calendar year, and will � <br /> repori Ihe same payments to lhe Intemal Revenue Service. <br /> . <br /> I accept the payment of the Backwa�er Prevention Device rebate from the City of Everelt pending : <br /> approval of the completed 8ackwaler Prevention Device rebale package by lhe City of Everett � i <br /> -0 � °J� �`'-tn— I I - � I - I N <br /> Signalure oF Contracfor Date <br /> I <br /> I <br />