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Contractor Section: <br />— — -- - _ _ . _ ----- __ _ _ - -- <br />� <br />i M J � �'L,., h., , �, o��, � �� � �t�� <br />i Vendor Name / Business Nar�/ UBI Number <br />� �'l�cf, ��� �S� 5 � (� - -- - - <br />� State of Washington Contractor License Number <br />I'� 17Si S �iL Sf- S,L _ C,,�G,Lr-�,��G. L✓i3' �?�i25O I <br />Vendor Mailing Address City State Zip � <br />I � <br />� Phone <br />� G� (.1 I i=r_.-��"� r�-� v-e�, � l <br />Email <br />>..�/ . LUi`"'` <br />� <br />I. Ihe V�tndor, agree to receive the Back�vater Prevenlion Device rebate check directly for the <br />instailzlion at Qie above referenced property address. [iy agreeing to receive lhe rebate check <br />directly, I agree b lhc following: <br />1. The Backwater Prevenlion Device rebale amount �vill be deducted (rom the final invoice <br />given �o the property owner for the insta!lalion al �he property address referenced above, d <br />the lotal cost of the installation is greater lhan the rebate. <br />2 I, the Vendor, am a N�ashinglon State licensed conlraclor. . <br />3 The Ciry of Everell will send a�Federal Form 1099 b11SC lo me, the Vendor, for Backwater <br />Prevention Device rebale paymenis totahng more than S600 per calendar year, and w.ill <br />report lhe same payments lo the Internal Revenue Service. <br />I accepl the paymenf of the Back�vater Prevenlion Dewce rebale from the Cdy o( 6verett pending <br />approval o� ihe completed Backwater Prevention Device rebale packaye by the City o( Everett <br />0 � ` <br />� / 7� <br />Signature of Contraclor <br />Dale <br />