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� <br /> � <br /> i <br /> � <br /> ; <br /> ; <br /> Contractor Section: ; <br /> �-- —-- — � <br /> j � �I�JI�+���Ih h.1� C � <br /> �, Vendor Name /Business Name I UBI Number � <br /> � (��p��PL`�o3�t ; <br /> , <br /> State of Washington Contractor License Number. � <br /> 5�Y07 7/�F , ��,�y„�r,/[ �t/i3 ��_p � <br /> Vendor Mailing Address , City State Zip <br /> �yzs ;�7' -I��`7 {�e�bi e�,,���;�a{��-�� ; <br /> Phone Email <br /> � ' <br /> ---- -- ---- — I I <br /> --- --- � <br /> �, Ihe Vendor, agree to receive the BacMvater Prevention Dev:ce rebate check duectly tor ine � <br /> ins;alla;ion at the above referenced property address. By agree�ng to receive the rebate check <br /> directi/, I agree;o;he (olb�.ving <br /> 1 The Backwaler Prevention Device rebate art:ount�vili be deducted from the 5nal invoice . <br /> g�ven to Ihe proper,y o�timer for the instailation at Ihe property address referenced above, if � <br /> the to:al cost of Ihe installation is greater than the rebafe <br /> ? I, Ihe Vendor, am a YJashington Stala licensed cortractcr <br /> ;. t r.e City o`Everett v+�li send a Federal Form 1099 MISC to me. the Vendor, for Backwater � <br /> Prevention Device rebate payments totating more ihan 5600 per caiendar year, and Lvill I <br /> reoort lhe same paymeMs te Ihe In?emai Revenue Service <br /> - -- - --- ---- -- -- _---------� i <br /> I accep!the oayment of th�� �achtivater prevenlion Device rebate fro� the C.ly of Everelt pending • <br /> approval o(Ihe completed Hac4:water Pievenlion Dzvice rebatc package by Ihe Cdy o( E�•erett <br /> i / � <br /> � <br /> �� -- � yf � 1 <br /> onMactoi �pa�z i <br /> � Li 1 <br /> L_ __ _ - -- -- - ---- - - i <br /> � <br /> I <br />