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Coritractor Section: <br /> �_f�'zLL�___f��u M j �n/G (�.>' —oJ � - ci S S�' <br /> Vendor Name !Business Name/ UBI Number <br /> �G1 f�� -G� J <br /> State of Washington Contractor License Number: <br /> S�G7 �7/j_~�i/� Ni'. M/�IZYSiJi1.�L �N/3 l�. "Z, cJ <br /> Vendor Mailing Address City State Zip <br /> :.�rys � ._1�07 <br /> Phone ` Email <br /> I, ihe Vendor, agree to receive the 8ackwafer Prevention �evice rebate check directly for the <br /> inslallation at ihe above referenced property address. By agreeing to receive lhe rebate check <br /> directly, I agree to the following: <br /> 1. The Baektvater Prevantion bevice rebate amoun't�vill be deducted irom the (inal invoice <br /> given to the property owner for the installation at the property address referenced above, If <br /> the total cost of the installacion is greater than the rebate. <br /> 2. I, the Vendor, am a VJashington State licensed contractor. <br /> 3. The City of Evereri v�ill send a Federal Form 1099 �viISC to me,the Vendor, for Baciovaler <br /> Prevention Device rebate payments tolaling more than 3600 per calendar year, and �vill <br /> report ihe same payments to the Internal Revenue Service. <br /> I accept the payment of Ihe Dacicwater Prevention Device rebate from the City o�Everett pending <br /> approval of th2 completed f3acLwater Prevention Device rebate packape by ihe Ciry of Evereft <br /> � � �S <br /> Signature of Contractor _. . Date <br />