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i - <br /> � <br /> � <br /> � <br /> Contractor Section: <br /> i z=�7�= 8 3 <br /> � � <br /> z�,4 �(�,�-, b.l c..c � �?��_�,,+�-� �w�`Z. �' <br /> Vendor Name /Business Name/ UB Number <br /> � r�eLr � a���n , <br /> 5tate of Washington Contractcr License Numher. <br /> � �Cr� �I U i S`�rc�n� E'�`'� -��i �-.�`i- `�d� °� <br /> � Vendor �lailing Address City State Zip <br /> ��-�—`{$9 - �cZ� rR.�4- a�w b��^s �c� �-Y�iC��3�.a:(• c �- <br /> i Phone Email <br /> � <br /> i -- <br /> I <br /> � I, the Vendor, agree to receive lhe Backwater Prevention Device rebate check directly(or the <br /> � installation at the above reterenced property address. By agreeing to receive lhe rebate check <br /> i <br /> direclly, I agree to the following: <br /> 1. Ttie Backwater Preventiun Device rebate amounl will be deducled from the final invoice <br /> given lo lhe property owner tor the installation at the property address referenced above, if <br /> the lotal cost o(the installation is greater than the rebate. <br /> 2. I, the Vendor, am a Washington State licensed contractor. <br /> 3. The City of Everett wiil send a Federal Form 1099 MISC to me,the Vendor, for Backwater <br /> Prevention Device rebate paymen(s lotaling more than 5600 per calendar year, and will <br /> report the same paymenls to the IMemal Revenue Service. <br /> — i <br /> i I accept Ihe payment of the Backwaler Prevenlion Device rebate from the Cily of Everell pending <br /> approval of the completed Backwater Prevention Devir,e rebate package by the Cily of Everetl <br /> � <br /> i <br /> /—i 9—/5 � <br /> Signature of Con�ractor Dale <br /> � - — <br /> I <br /> � ' <br /> � <br /> I <br /> � � � <br />