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� 1:' <br />a <br />� <br />Contractor Sectlon: <br />1 <br />! UBI Number <br />ete f Washington Coniractor License Number. <br />..� ��%3� N� �l,i� i�� �'nZ�s� <br />,' Vondor Meiling Address • City Stale Zip <br />' -� "�% � �ifi� ,r.��t,(t' a�� ti�yz�� �r^� ��M � <br />� Phone —_� Emall <br />0 <br />1, the Vendor, agree to receive Ihe Ber,kwater Prevention Device rebate eheck direclfy tor the <br />InstaliaGon at ihe above refe;enced property address. By agreeing to receive the rebate check <br />direcliy, I ag�ea to lhe foltowing: <br />1. The Backwater Prevenlidn Oevice rebate amounl wlll be deducfed t�om ihe final invoice <br />given lo the property ownar for ihe (nstallalbn al lhe property address roferenced above, If <br />the totat cost o1 the installation is grealer than the rebate. <br />„� � 2. I, the Vendor, am a Washington State IlCensed conira�;tar. <br />3. The City of Everett will send a Federal �orm 1099 MISC to me, the Vendor, for Backwater <br />Prevention Device rebate payments totaling more than 5800 per calendar year, end �vill <br />' ropart the samc paymonlo to the Inlernol Revenue Service. <br />I accept the payment of the Back�vater Prevention Uevice rebate hom lhe City of Everett pending <br />approval of lha compieted Backwater Prevenllon Device iebate package by the City of Everett <br />F <br />��--� <br />Date <br />