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Contractor Section: <br />�.�1,`t,� � j L '�,�� LL C, �c� -'� .3_ L ' �:3 <br />i�i.-r • /l .� __ I.C�_�-QL�._-.?����-1-- � -�----- _ '�' <br />Vendor Name I Rusine. s Name! UBI Number <br />! __9 `ri_� G.:Lt� `�� �K�- - - — _ - - ---- -- <br />State of NJashinylon Coniracror License Number. <br />� L� '1� ��,'t���jf __��.7�����_ao,� <br />, �(��i�_._-�.c�►�_ _P-,• -- <br />I Vendor tviailing Address City Stale Z�P <br />aL;��_k�_Ln�?�°� <br />Phone <br />L�'��L� c�._:�:� c,� •���(�D �_G�:ti <br />Email <br />I, the Vendor, agre2 to receiva the 4?�k�vater Preventio� Device rebate chec4 directly tor the <br />installation at fhe above referenced property address. By agreeing to receive lhe rebate check <br />r.irectll�, 1 agrr.e lo ihe fotloering. <br />t. The Bar.kv;ater Prevention Device ret�ate amount will be deducted from the final invoice <br />given to the propr.rty owner (or Ihe instalia!ion a; the proper;y address referenced above, i( <br />tho lolal ccst of the installation is �reater than ihe re�ate. <br />2 I, the Vendor, am a VVashington State Gcensed coniractnr. <br />3. The City of Everett �viil send a Federal Form 1099 MISC to me, thc Vendor, for [3ackc��ler <br />PreveNion Device rebale payments toialing more than $��0 per calendar year, and caill <br />reporl the same payments to 1he Intemal Revenue Service. <br />�;�c�epl ��ie payment ot the Hackwaler Prevention Device rebate from ihe <:itY o` Everetl pending <br />approval o( Ihe completed Hack�valer Prevention Device rebate par,kage by the City of L=veretl <br />C�� �, <br />� ' G'�c_z— - <br />Sig�iature of Contraclor <br />-?� l �� ��- - <br />o�rte <br />