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Contractor Section: <br /> �'o¢rt �;�1 cs������;•,as'�r..x,(•„¢E ��i I - �y`� - O `�f`� 1 <br /> Vendor Name/Eiusiness Name I UBI Number <br /> _ n,2iHi. ����✓ L `� ---- - <br /> . State of Washington Contractor License Numbec <br /> '�� J 3�x Sl�'7 _ y��2�,N:y�o�v-- �.J/t �I�'�-'/-�j <br /> --�-- <br /> Vendor Nailing Address Ciry State Zip <br /> � `I9-� ) 3nt i 533 N �,.t ;����LIa'�i�LJc.k"JhC (�� Y,2�i���c,.�� <br /> Phone Email <br /> I,the Ve,idor, ayree to receive lhe Backwaler Prevention Devia: rebate check directly for the <br /> installation al Ihe abo�re referenced property sddress. [3y agreeing to receive Ihe rebate cher.k <br /> directfy, I agree lo the follo���ing: <br /> 1. The Backedater Prevenlion Device rebate amount�vill be deducted from the final invoice <br /> given to lhe property ov:ner for lhe insfallation at the property address refemnced a6ove, if <br /> the lolal r.nst of the inslallalion is greater lhan thc rcbafe. <br /> l. I, lhe Vendor, am a Washington Stafe lic;ensed conlrs�r,tor. <br /> 3. The City oF Fverett will send a Federal Form 1099 MISC tn me,the Vendor, for Backu�aler <br /> Prevention Davico rr.bate payment� lotaling more than�fiDU per calendar yr,ar, and will <br /> rcport ihe samc paymr,nis to lhe In�emal Revenue Service. <br /> I accepl lhe payment o(the Backwater Prevention Device rebale(iom the City of Everr.lt pending <br /> approval of ihe cotnpleted 13.ir.kwater Prevenlion Devicr. rebate package hy the City of[veretl <br /> C/_�- � l3/iS <br /> ��/�- --- - --- -- � <br /> Signalure of Cnntractor ��j�e - — I <br /> 1 <br />