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Contractor Section: <br />Mut,^ ��(t,�„�-� <br />L�J <br />Vendor N3me / Eusines�Name / UBI Number <br />1'� � Pl� �� � 3 � v <br />State of Washington Coniractor License Number: <br />17Slf�(�S' j� S� S��,v,h�;c, wl�" �l��v <br />Vendor Mailing Address City State Zip <br />�i �- S 7G U <br />Phone <br />� <br />'� � A � � -v� <br />Email <br />aor <br />I, the Vendor, agree to receive the Backwatcr Prevention Device rebate check directly for the <br />inslallaUon at the above referenced property address. By agreeing to receive the rebate check <br />directly, I agree to the (ollowing: <br />1. The Backwater Prevention Cevice rebate amount will be deducted from the final invoice <br />given io the property owner for the inslallation at the property address re(erenced above, if <br />lhe total cosl of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washinglon State licensed contractor. <br />The City of Evereti will send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br />Prevention Device rebale payments totaling more than 5600 per calendar year, and will <br />report Ihe same payments to Ihe Internal Revenue Service. <br />I accepi the payment of the Backwaler Prevenlion Device rebale (rom the City of Everett pending <br />approval of the compteted Back�valer Prevention Device rebate package by the C�ty of Everetl <br />�`�I U� �'�'_'. <br />Signature ot Contractor <br />7—IS— f S <br />Date <br />