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t <br />I <br />I <br />Contractor Section: <br />,j <br />Vendor Name / Business Name ! UBI Number <br />A��LG/'L;�3Li _._ <br />State of Washington Contractor License Number: <br />5�/u7 7l�A�c ,✓F M�+iysv�!iP- ^-✓y �fl�-7C/ <br />Vendor Mailing A�dress City State Zip <br />�S — iso7 <br />Phone <br />Email <br />i, Ihe Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <br />instailation at t'�e above referenced property address. By agreeing to receive the rebate check <br />direcUy, I agree lo lhe following: <br />1. The Backwater Prevention Device rebafe amount will be deducted from theiinal invoice <br />given to the propeAy owner for the. installation at the p��perty address re�erenced above, if <br />the total cost of the installation is greater than the reb3te. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br />Prevention �evice rebale paymenls totaling more lhan $600 per calendar year, and �vill <br />report the same payments to the Internal Ree �ue Service. <br />I accept the payment ot lhe Backwater Prevention Device rebale trom the City ot Everett pending <br />approval oi the completed Back�vater Prevention Devir.e rebale package by the Ciry of Everett <br />Signature of Contractor <br />���9//r <br />Date <br />