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l <br /> I <br /> i <br /> ; <br /> � <br /> I <br /> i <br /> Contractor Section: i <br /> -- -- � <br /> —�J�U��Uf_I� '(�bu-' ►� _ ! <br /> Vendor Name I Business Name I UDI Numher � <br /> IJ�SG�-v'sDgi�3P (3 _ i <br /> Stale of Washington Contractor License Number: <br /> V t� �� 5�.�" � Slto✓e.1�vc.c� (,�1�- ��' 155 <br /> Vendor Mailing Address City State Zip ` <br /> . i <br /> `1-U6 �31 . 7�?� ��n.�1rli�i��� ���se�.ueV.[� ; <br /> � , <br /> I Phone Email ; <br /> j <br /> � <br /> 1, the Vendor, agree to receiva the Backwater Prevention Dcvice rebale check directly for lhe ± <br /> installation at the above reterenced property address. By agreeing to receive the rebate check � <br /> directly, I agree to the following: j <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final Invoice j <br /> given lo lhe p�operty owner for the installation at Ihe property address referenced above, if { <br /> the total cost o(the installation is greater Ihan the re6ate. i <br /> 2. I,the Vendor, am a Washington State licensed contraclor. ' <br /> 3. The Ciry of Everett will send a Federal Form 1099 MISC to me, the Vendor, for Backwatcr j <br /> Prevention Dovice rebate payments totaling moro than 3600 per catendar year,and will ' <br /> repoA the some paymenfs to the Internal Revenue Service. , <br /> � <br /> — -- ---- i <br /> I accept the payment of the Backwater Prevenlion Device rebale irom the City o(Everett pending ! <br /> approval of the completed Backwaler Prevention Device rehate package Uy the City of Everelt <br /> i <br /> i � <br /> / � <br /> . � <br /> �-1 ��-- -� �-� �s ! <br /> i <br /> Signature of CoMractor Uate i <br /> ----- — -- I <br /> I <br /> i <br /> i <br /> i <br /> i <br /> � <br /> � <br /> 1 <br />