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i <br /> I <br /> � <br /> � <br /> ; <br /> Contractor Section: � <br /> � <br /> _ ; <br /> �i ����,, I�l�� �,h ��� � � � G ��l_ `t�1� I <br /> Vendor Name 1 Business Name UBI Number 6 � <br /> Mven ��� �` �8 3. 1` D � <br /> I <br /> State of Washington Contractor License Number: i <br /> i 75 I S �I I � SI 5/= Sn��,cr�� t'� �"�� "I�o�CiU j <br /> Vendor ��4ailing Address City State Zip � <br /> �1.2 7 " U 4s36U T,-<� w I <br /> s � E c ,���, r�i�,,�-,hr�� , ��,�, ; <br /> Phone Email � <br /> i <br /> - - ----- -- I <br /> I <br /> I, the Vendor, agree to receive tne Backv�aler Prevention Device rebate check directly for the � <br /> installation at the above referenced propert�address. By agreeing to recelve the rebate check � <br /> directly, I agree to ihe follo�ving: � <br /> i. The Backwater Preventlon Device rebate amount e�ill be deUuc[ed from lhe hnai invoice <br /> given to the propertv oe.�ner for the installation at thc property address referenced above, if <br /> fhe total cos[of the installation is greater[han Ihe rebate. <br /> 2. I, the Vendor, am a Washington State licensed contractor. � <br /> 3. The City of Everett will send a Fe;arai Form 1099 MISC to me, the Vendor,fur Backwater ; <br /> Prevention Device rebate payments totaling�nore than �600 per calendar year, and will i <br /> ;eport the same payments to the Inlernal Revenue Service. <br /> i <br /> I <br /> r-- ----- — — -- <br /> iI accept the payment of the 13ackwater Prevention Device rebate from the City of Everett pending <br /> � approe�al of the complefed Backivater Prevention Device rebate packat�e by�he City of[verett <br /> i <br /> i <br /> °�.r�� "�! `�y2��. �-f-�5-� S' . <br /> Signature of Contractor Date <br /> L � <br /> � <br /> f <br /> i <br /> � <br /> i <br /> i <br /> 1 <br />