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Contractor Section: <br />�LlO��i.�..�"11� f�.----�� 3 _ � a.S <br />Vendor Name! Business Name / UBI Number <br />i � <br />j �LL�� � G � <br />i State of Washington Contractor License Number. <br />S�7 �/s� �ci� /�'1G✓�5 i/�Lf� i'"�' %��%�/ — <br />Vendor Mailing Address City State Zip <br />3�7 -i�.7 ___ <br />Phone Email <br />I, the Vendor, agree ro receive Ihe Back�valer Prevention Uevice rebate check directly for !he <br />instaPation at the abcve referenced property address. By agreeing to receive the rebate check <br />directly, I agree to lhe foilo�ving. <br />1 The Backwater Prevenl�on Device rebate amount �•+ill be deducled from the final invoice <br />givzn to the property o+n�ner for the installation at the property address referenced above, if <br />the lotal cosl o( the instaila6on is greater than ihe rebate. <br />2 I, the Vendor, am a\�'aslungton State licensed contractor. <br />3 The Cdy of Everelt will send a Federal form 1099 tv11SC to rne, the Vendor, for [3ackwater <br />Prevention Device rebafe paymenls totaling more than SG00 per calendar year, and �vill <br />report the same payments to lhe Internal Revenue Service. <br />I accepl Uie paymenl of the Backwater Prevenlion Device rebale from lhe City of Everelt pendiny <br />approvel of lhe completed E3ackwater Prevention Device rebate package by the City ot Everell <br />� <br />Signature of Contractor <br />_ J�Z,i _ iS"� <br />Datc <br />