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i <br /> i <br /> i <br /> Contractor Section: ' <br /> ; <br /> /, � � �, _�_�! ;t`� . ljC�lck; L[,,C� i�.;_r,•�• ?J-`ta?3 <br /> �-U�Y`-iut�l-i�--...-- �- <br /> � Vendor Name 1 3usir�e�ame I UEI Number <br /> , I <br /> �Nt.�C��.��-� �-i--K-� - , <br /> Slate of Washington Contractor License �umber: <br /> --��[r, L�t.r l i►'Z___(�2,� ' �-C�'�-1•��' �'_�_a�� <br /> Vendor Mailing Address City State ZiP <br /> / _ _ i <br /> '�[`fo-�/c7�t�,4a�C��s_f" � C.t�_ ,�.�.� c° ' t� ��[x �, C�r�i�_ � <br /> Phone Email � <br /> �- — � <br /> I, the Vendor, agree to receive the Back�.valer Prevention Device reb2le check direcpy for the � <br /> installation at the ahove referenced property address. 8y agreeing to reccive the rebale check <br /> directly, I agree lo tlte (ollowing: <br /> 1. The Back�ti�ater Prevention Device rebate amount will he deducted from the final invoice <br /> given to tho property o�vner for lhe installation at the property address referenced above, if ; <br /> the total cost of the installation is grealer H�an the rebale. <br /> 2. i, the Vendor, am a Washington State licensed contractor. • <br /> 3. The City of Evcrett�vill send a Federai Form 1099 MISC to mc, the Vendor, for Backwater ; <br /> Prevention Device rebate payments totaling more than $600 per calendar year, and will <br /> report the same payments to the Internal Revenue Service. <br /> _ I <br /> f accept the payment of the Backwater Prevention Device rebate irom the City oF Everett pending � <br /> approval of the completed Backwater Prevention Device rebate package hy ihe City of Everett <br /> i <br /> i <br /> ����_ � �:�' -�J a�-ll�— ° <br /> Signature of Contractor �ate ' <br /> � <br /> --- � <br /> � <br /> � <br /> i <br /> i <br />