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i <br /> � <br /> ; <br /> � <br /> � <br /> ConYractor Section: j <br /> — — 1 <br /> ; - , � _�iL� �c_.�..�-�' f' `-�.E=t-t ' LLG r;c>�• ; .�3 � i <br /> Vendor Name/ Ciusine s Name I UBI Number � <br /> � <br /> A__���-.`_;`�-� ��- - _ ; <br /> State of�Nashinyton Contractor License Number. ; <br /> � <br /> �s�4o E--�L���—'i (� P� �tv����'�' '+ �,d.7r �� �i.� i <br /> Vendor Mailing Address City Slate Zip ' <br /> i <br /> �fn-.a�1���P'i�� �`Y'lt��_Ci_C���'--��?:�-�c.�'�7��e-�'GiJ_� ' <br /> � <br /> Phone Email <br /> � <br /> i -- <br /> I, ihe Vendor, agree to receive lhe dackwater Pravention Device rebate check directly for lhe ; <br /> installation at the above referenced properly address. By agroeing lo receive the rebate check ! <br /> direcUy, 1 ac�rze to the following: � <br /> 1. The Backwaler Prevenlion De��ice rebale amount will be deducted from the final invoice � <br /> given to the property owner for ihe installalion at the property address referenced above, if <br /> the tolal cost of the Installation is greater than ihe rebate. '. <br /> I <br /> 2. I, the Vendor, am a Washinglon State licensed cnntractor. ; <br /> 3. TI'�e Cily of Everelt�vill send a Federal Form 1099 MISC to me. Ihe Vendor, ior Backwater <br /> � <br /> Prevention Device rebale payments totaling more than 5600 per calendar year, and will i <br /> reporl the same payrnents to the Internal Revenue Service. I <br /> i <br /> ---- -- — - - i <br /> I accept lhe payment of lhe Backwater Prevention Qevice rebate irom the City of[verett pending I <br /> approval of the complefed Backvaater Prevention Device reba[e package by lhe Ciry of[vereit i <br /> /� � � <br /> �> � <br /> �• -�-�— n c�._ - - .�(._ �` <br /> Signature of Con[raclor Date ' <br /> I <br /> - — ---- --- � <br /> ---- —__ --- _ _ __ : <br /> _---- -- ---- i <br /> I <br /> i <br /> i <br /> i <br /> i <br /> i <br /> i <br /> tik <br />