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Gontractor Section: <br />�� ULa� I,��nrti ��, !1 <br />Vendor Name I Business NarY <br />e 1 UBI Number <br />G L% � CiS'�9 ��i �-/.� � <br />M o e_n P/' .� �' �� 51; — <br />State oi Vt�ashington Contrac'or License Number: <br />� �S is �r�='� 5r SC 5:��/-,�,ti, til, i✓14 �Y7 �i� <br />Vendor Mailing Address City State Zip <br />�l�S 7((: S'� <br />Phone <br />Email <br />rvi �t'.n ��1�,.-,l��r��i c��rh <br />I, the Vendor, agree to receive the Backtvater Prevention Device rebate check directly for the <br />installation at the above referenced property address. By agreeing io receive ihe rebate check <br />directfy, I agree to the folla�ving: <br />1. The Backwater Preventlon Oevice rebata amount will be deducted irom ihe final invoice <br />given �o the pro�erty owner for the installation at the property address referenced abovo, if <br />the lotal cost of the instaliation is greater than the rebate. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. The City of Everett will send a Federai Form 1099 MISC to me, the Vendor, for Backwater <br />Prevention Device rebate payments totaling moro lhan $600 per calendar year, ano �vilt <br />report ihe sarne payments to the Internal Rovenuc+ Service. <br />� I accept Uie payment of the Backe+aler Prevention Device rebale (rom the City of Everett pending <br />i approval of the rompleted Bac{avater Prevention Device rebate packagc by lhe City af Evereri <br />✓ �W� 9 %3� �Lr.� <br />S��'�� <br />Signature of Contraclor Dale <br />