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i <br /> _ ; <br /> � <br /> : <br /> Contractor Section: � <br /> i <br /> � <br /> � <br /> �er,������+--.�1 ���lp ���C(,C, �.r,��8 I <br /> Vendor Name f Business Name/UBI Number ! <br /> � <br /> �M��-LS� Wol KL_ i <br /> State of Washingron Contractor License Number. � <br /> I <br /> �-r� ►�rl�,��� . E��l�L-R� <br /> Vendor Mailing Address Ciry Slate Zip <br /> ' I <br /> ��C�-���— ����(SYi'1',('i�9��qf�lc:I)v!-f<Stcj��Cd�77 � <br /> Phone Emaif <br /> I � <br /> � <br /> i <br /> I,the Vendor,agree to receive Ihe Ba kwaler Prevention Device rebale check direclly ior the � <br /> installalion al lhe above referenced pr�perty ad�lress. By agreeing lo receive the rebate check <br /> � � direclly, I agraa to ihe following: � <br /> 1. The Backwater Prevenfion De ice rebate amount will be deducted from the final fnvoice � <br /> given to the property owner fo the Installation at the property aAdress referenced above, If ; <br /> � the lotal cost of lhe installation is greater than lhe rebate. I <br /> i <br /> 2. I,Ihe Vendor,am o Washington State licensed contraclor. ! <br /> � <br /> 3. The City of Everett will send a Federal Form 1099 MISC lo me,the Vendor,for Backwater � <br /> Prevenlion Device rebate payments totaling more than$600 per calendar year,and will � <br /> report the same payments to Ihe Inlernal Revenue Service. � <br /> � <br /> — � <br /> _ � <br /> I accept the payment of the Backwater Prevention Device rebate trom the City ot Everett pending <br /> approval of Ihe completed Backwaler Prevention Device rebale package by the City of Everelt <br /> I <br /> .�'.� . �.,-�. �.�- i <br /> Signature ol CoNractor Dale i <br /> I <br /> � <br /> i <br /> � <br /> I <br /> j <br /> � <br />