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Contractor Section: <br />l�1 ven ����Mh, -,1� �LC C�63 -'-1�:�3- s��`� <br />Vendor Name / Business Name'/ UE31 Number <br />� M(i C'_/` P P't` K?�/ 5.) i� _ ------ -- <br />State o` Nlashington Contractor License Number. <br />I 175 i5 �fl`x Sd Sr 5,����m��� wk� �rb�2�i� <br />Vendor Mailing Address Ciry State Zip <br />y�11— 7G�U �3�c3 i r�,n� `c� n-�az„ -l�„rh-�, .�;.,—� _ <br />Phone Email <br />I, the Vendor, agree to receive the �acktivater Prevention Device rebate check directiy for the <br />installation at ihe above referanced propeKy address. By agreeing to receive the rebale check <br />directfy, I agree to the (ollotti�ing: <br />1. The Bac�vater Prevention Device rebate amount �vill be deducted from ihe final invoice <br />given to lhe property o�vner for the installation at the property address referenced above, if <br />the lotal cost of the inslallation is greater than the rebate. <br />7. I, the Vendor, am a Wash ngten State licensed contractor. <br />3. The City of Everett will send a Pederal Form 1099 MISC to me, the Vendor, ior Backwater <br />Prevention Device rebate payments totaling moie lhan S60C per calendar year, and will <br />report Ihe same payments to ihe Inlcrnal Revenue Service. <br />I accept the payment of lhe BacMvaler Prevention Device rebate from llie Ciry of Evere�t pendinr�� <br />approvai of the completed Oacic�vater Prevention Device rebat� package hy the City of Everett � <br />-� � <br />' G �------ %" �tf' — I.SJ -- <br />Signature o( Conliaclur Date <br />