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, <br /> � ; <br /> i <br /> ; <br /> � <br /> � <br /> ; <br /> Contractor Section_ i <br /> I � �G� j3- `.. ,tc �� LLC. ._(c>_s-'` ��i.'�'' -3 j <br /> ��:1�'?---�„ r-- , <br /> Vendor Name 1 Busine s Name/UBI Number � <br /> . <br /> �=1-�1�,=-�-=J-_�.lr.'�f�L' -- � <br /> State of Washington Contraclor License Number: � <br /> �.4s�%�Lr.�cLiU-��,.—���rQ1-�l�7��'��:� I <br /> Vendor Mailing Address City State Z�P ± <br /> ����g�_______ ����1,��� � <br /> I Q•�xl�Lis:���:�C_..` <br /> Phone Email � <br /> � <br /> � <br /> � � i <br /> I, the Vendor, agree to receive Ihe Backwater Prevention Device rebate check direclly for the � <br /> installation at the above referenced property address. By agreeing lo receive the rebate check � <br /> directly, I ac�ree lo the follov�ing: M <br /> 1. The Backwater Prevention Device rebate amount will be deducled from the finzl invoice <br /> f <br /> given to the property owner(or lhe installalion at the property address referenced above, if i <br /> Uie lolal cost of the inslallation is g�eater than the rebala <br /> 2. I, lhe Vendor, am a Washinglon State licensed coNraclor. � <br /> 3. 7he City of[verclt will send a federal Form 1D99 MISC to me, Ihe Vcrdor, for Backwater 4 <br /> Prevention Device rebate payments totaling more than�600 per calendar year, and wiil <br /> repoA the same payments to the Internal Revenue Service, � <br /> I accept !he pay <br /> ment of the Backv+ator Prevention Device rebate fwm the City of Everett pending i <br /> approval of the completed f3ackwater Prevention Device rebate package by lhe City of Everett i <br /> C� � � .�' ��15 ; <br /> z�.,.t'. � ���� <_ <br /> Date " <br /> Signature of Contractor <br /> { <br /> �-------— _ --- - ---— i <br /> � <br /> � <br /> � <br /> � <br /> � <br /> i <br />