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, <br /> - - � <br /> , i <br /> � � <br /> i � <br /> I <br /> � <br /> Contractor Section: <br /> ! —�— —- i <br /> '' ��1�<� � � a� �wr�f� �v� - a� l�'� � <br /> f ____ ' <br /> Vendor Name 1 Business Name/UBI Numher <br /> ��s��ss `L � 5 <br /> , State of Washington ContraZio License Number. , <br /> � ���3 �36y 1� �-{�cJ. �c���'��s �A `���6 <br /> I Vendor Mailing Address City State Zip <br /> �r:6-�l1�- y�9'3 A�u�e�f�'��.,d� se,,�,e�z. ca 6a�u;/cd�.� <br /> Phone Email <br /> i <br /> �I � <br /> � I,the Vendor, agree to receive the Backwater Prevention Device rebate check directly for the , <br /> installation at the above referenced property address. By agreeing to receive the rebate check <br /> direcUy, I agree to the following; <br /> 1. The Backwater Prevention Device rebate amount will be deducted fram the tinal invoice <br /> given to the property owner for the installation at the property address referenced above, if <br /> Ithe total cosf of the installation is greater lhan the rebate. <br /> 2. I,the Vendor, am a Washington State licensed contractor. <br /> i <br /> 3. The City of Everetl will send a Federal Form 1099 MISC�o me, the Vendor,for Bachwater i <br /> I Prevention Device rebate payments totaling more than 5600 per calendar year, and will <br /> Ireporl It�e same payments to lhe Intemai Revenue Service. � <br /> i <br /> I accept ihe payment of the Backwater Prevention Device rebate from the City of Everelt pending i <br /> approval of the completeA Back�yater Prevention Device rebate package by ihe City of Everett ; <br /> � �, ��`� 2,-��-�1� <br /> �S na ' of Contractor Date <br /> I - <br />