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7 <br /> . i <br /> i <br /> � <br /> � <br /> � <br /> Contractor Section: � <br /> i <br /> f <br /> �rt/�it 121 ���<' � t i . ._ LL�"��>C.'�� ;3��-�:-'3 � <br /> Vendor Name/Ciusine.s Name/UBI Number � <br /> i <br /> _��i1-.`�-J–.�f�---�' — • <br /> State of Washington Contractor License Number. <br /> �� L� T I�i`Ll (� Q—���-1�_1�(.�`��'�r�'�Sa��%� ; <br /> Vendor Mailing Address City State Z�P � <br /> ���n��?t7��_C'ct�.LCs�f' ��-�-�--�- �-�`"--Jn ( O�rr�/22_ � <br /> Phone Email ' <br /> i <br /> i <br /> I, the Vendor, agree lo receive the Backwater Prevention Device rebate check directly fcr the � <br /> inslallalion at the above referenced property address. By agreeing to receive the rebate check I <br /> directly, I agree to the following: ' <br /> 1. The 8ackwater Prevention Device rebate amount wiil be deducted from the final invoice i <br /> given to the property owner for lhe installation at the property address referenced above, if � <br /> ' ihe tolal cost of the installation is greater lhan the rebate. i <br /> 2. I, the Vendor, am a Washinglon State licansed contraclor. i <br /> 3. The City of[verett will send a Federal Form 1099 MISC lo me, the Vendor,for Backwaler : <br /> Prevenlion Device rebate payments totaling more than $600 per calendar year, and�vill , <br /> report the same payments to the Internal Revenue Sen�ice. ; <br /> � <br /> 1 accept lhe payment of lhe Back�vater Prevention Device rebate from the City oF Everetl pending <br /> approval of the completed f3ackwater Prevenlion Devir.e rebate package hy the City of Everet[ i <br /> � <br /> i <br /> /� /�j ' <br /> C��u..�__�>-'�' — 1(� ' <br /> Signature of Contractor Date { <br /> � <br /> i <br /> -- -. I <br /> � <br /> ! <br /> i <br /> � <br /> i <br /> 1 <br /> 1 • <br />