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i .. . .�.. ♦ "�� <br /> < <br /> I <br /> I <br /> I <br /> I <br /> I <br /> � Contractor Section: <br /> � 1��� dS�� - --��� ���5— 11�- <br /> ; a� <br /> ; Vendor Name/Business Name UBI Number <br /> I' ' l9�So� ° � .� <br /> ; State o(Washington Co ractor License Number: <br /> � ���� �36 -�" s�:��• ��I m��I,s WA _g���6 <br /> Vendor Mailing Address City State Zip <br /> �'�lGs- �193 �u-��aur���e�a C�'n�a;�.��i <br /> , <br /> Phone Email <br /> I <br /> ! I, Ihe Vendor, agree to receive the BackwatPr Prevention Device rebate check directly for the <br /> ; inslallation at the above referenced oroperty address. By agreeing to receive the rebate check _ <br /> ; directly, I agree to the following: <br /> .:::;.. <br /> � 1. The Backwater Prevention Device rebate amount will be deducted from the final invoice <br /> � given to the propeRy owner for the installation at the property address referenced ahove, if <br /> I the total wst o(the ir.sialialion is greater than the rebate. <br /> ' 2. I,the Vendor, am a+Nashingion State licensed contractor. <br /> 3. The City of Everett will send a Federal Form 1099 MISC to me,the Vendor,for Backwater <br /> Prevention Device rebate payments totaling more than 5600 per calendar year, and will <br /> report the same payments to the Internal Revenue Service. . <br /> I accept the paymenl of the Backwater Prevention Device rebate from the City of Everett pending <br /> approval of the completed Backwater Prevention Device rebate package by the City of Everett <br /> i <br /> � C��- �-�l-ao�� <br /> i na re of Conlractor Dale <br /> j � <br /> .� <br /> � <br />