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! <br /> � <br /> � <br /> � <br /> f <br /> 1 <br /> � <br /> Contractor Section: � <br /> ! <br /> � � <br /> ��U_L�L1s: i1''1�s_Nv' (z�.>' — �i > - v S S� � <br /> Vendor Name I Business Name i UBI Number ; <br /> i <br /> { <br /> , �� f'� Ci�Li <br /> State of 1Nashington Coniractor License Number: ! <br /> i <br /> / 7 7/_�/�V�-- - � - <br /> S � S N�, �'YS����.: W� Q4?;o i <br /> � <br /> Vendor Mailing Ad9ress Ciry Sta,e Zip � <br /> �/�J ��s7 ''i�C�� ._ _ i <br /> i <br /> Phone ' Email I ; <br /> i <br /> _ —J <br /> I, the Vendor, agree to reczive the Back�vater Prevention Device rebate check direclly for the ; <br /> instailation at tho above refererced nroperiy address.8y e�reeing lo receive the rebate check � <br /> directly, I agree to tho iollo�ving: <br /> � <br /> L 7he Backovater Prevention Device rebate amount�a�iil be deducted irom the final invoice ; <br /> given to tho property c���ner(or Ihe installation at the property address referenced above, if � <br /> the total cost of Ihe installation is ar221er lhan the rebate. f <br /> 2. I, the Vendor, am a lNashington Si2i2 licenszd contractor. � <br /> 3. The City of Everett��oill send a Federal Fonn 1099 h11SC to me, !he Vendor, for Back�vatcr � <br /> Prevention Device reba�e payments totalin� more than 5600 per calendar year, and �vill ; <br /> report the same paymznls to Ihe Internal R�venue Service. � <br /> -- --_—. -- --- -- --� <br /> I ar,cept the payment o(Ine Back�a�ater Prevenlion Devlc� reb�to from lhe Cf�y of LvereU pending ' I <br /> approval of the compieted BacMvaler Prevenlion Devic.e reb2te package by the Ciiy of Lverett ; <br /> i <br /> � <br /> � <br /> i � <br /> ' - — --s-���r�-- -- f <br /> Sic�nature of Contractor _ Dale i <br /> � <br /> - ---- ---�- --� -'--------- � i <br /> I <br /> i <br /> I <br /> i <br /> i <br /> � <br />