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, <br /> . i <br /> 1 <br /> Contractor Section: . I <br /> �__ <br /> � ' �Jl' L� "� �i�E', �lf'li.�f',�� �(.� /r>C'��> ?C�.�.3 ; <br /> i <br /> Vendor Name I Busine�ame 1 UBI Number i <br /> A Nt r-F�-L.S�---���---�- i <br /> Slate of Wa:�hington Contractor license Number: <br /> i <br /> L 4� P _-.��/_�1_+-!,�_�-c'��. ' <br /> �'1G��i4�-�i� ,• � <br /> Vendor Mailing Address Ciry State Zip � <br /> i <br /> a����—���,�►�c���:��_�?�c�1��-, ��� i <br /> Phone Email ; <br /> 1 <br /> i <br /> I, the Vendor. agree to receive the Backwater Prevention Device rebate check dire�lly for lhe ; <br /> installation at the a6ove referenced property address. By agreeing to rece�ve ihe rebale check i <br /> directly, I agree ro lhe tollowing � <br /> i <br /> 1. The Backwater Prevention Device rebate amouni will be deducted from lhe finat invoice i <br /> given to the property owncr for the install2lion at the property address referenced above, if' <br /> Ihe total cost of the installation is greater than the rebate. ! <br /> 2. I, lhe Vendor, am a Washington State licensed contractor. <br /> 3. The Ciry of Everett will send a Federai Form 1099 MISC to me, the Vendor, for Back�vater <br /> Prevention Device rebate paymenis totaling more than$600 per calendar year, and wiil � <br /> repoA the same paymenls to the Intemal Revenue Service. <br /> � <br /> � <br /> I accept the payment of the eackwater Prevention Device rebate from the City of Everett pending <br /> approval of the compleled 8ackv�ater Prevention Device rebate package by ihe City of Everett ; <br /> i <br /> /1 ) � <br /> l�'4,��_ � �r"'-=�r-�C ____ �� � <br /> Sig�ature oi Contracror Date <br /> i <br /> • i <br /> i <br /> � <br /> � <br /> i <br /> i <br /> r <br />