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b <br />Contractor 3ection: <br />Vendor Name I Business Name / UBI Number <br />,�-�-p,��l�'o//P� — <br />State of Washington Gontraclor License Number: <br />�!/ ��Ya�_ i� � ..-��v�-�r.� 9d�v� <br />Vendor Mailing Address City State Zip <br />_ .�(zS= ��7- oYZ3 <br />Phone Email <br />�� <br />I, the Vendor, agree lo receive lhe Backwater Prevention Device rebate check directly for the <br />installation at lhe above referenced properiy address. By agreeing lo receive the rebate check <br />direcUy, I agree to the following: <br />1. The Backwater Prevention Device rebale amount will be deducted from the final invoice <br />given to the property o�•mer for the installation at the property address referenced above, if <br />Ihe total cost of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. The City of Everett will send a Federal Form 1099 MISC to me, ihe Vendor, for Backwater <br />Prevention Device rebate paymenls totaling more lhan $600 per calendar year, and will <br />report lhe same payments to ihe Intemal Revenue Service. <br />I accepl lhe payment of the Backwater Prevention Device rebate from the City of Everett pending <br />approval of the completed Backwaler Prevention Device rebate package by the City of Everett <br />(l�—/ � <br />Signalure of Conlractor Date <br />