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I <br /> . ! <br /> I <br /> � <br /> � Contractor Section: I <br /> � <br /> --� �, ���it�s'.� 't� '� LLc� �,>.;� ,-��.� I <br /> ���-—�'- = <br /> \!enuor Name!Busine�ame; UBI Numher � <br /> I <br /> �t�_�-� r.z-�-�-��-K-�--- � <br /> State of Washington ConUactor License Number. ; <br /> a�o� �4i' i�'1 (� . ���_ L�(._�—���� � <br /> Vendor Mailing Address Giry Stala Zip ; <br /> � <br /> �_�r-1�L���_G'�dsL_i_s;_t'��_���Crl'�? j <br /> Phonc Email i <br /> � <br /> � <br /> I, the Vendor,agree to receive lhe Backwater Prevention Device rebate check directly tor the , <br /> installalion at the above reterenced property address. By agreeing to receive ihe rebate chech : <br /> directly, I ar�ree�o lhe following: <br /> 1. The Back�vater Prevention Device rebate amount will be deducted from ihe final Invoice � <br /> given to lhe property owner for lhe installalion at the property address referenced abovc, if � <br /> the total cost of the installation is grealer ihan the rebate. j <br /> i <br /> 2. I, the Vendor, am a bVashington State licensed contractor. � <br /> 3. The City of Everett will send a Federal Form 1099 MISC fo me,lhe Ve�dor, for Backwater � <br /> Prevention Device rebaie payments lolaling more than SRDO per ca!endar year, and will <br /> repoA the same payments to the Inlemal Revenue Service. <br /> ----- — — --- — � <br /> I accept [he payment of lhe Hackwater Prevention Device rebate from the Ciry o(Everett pending ' <br /> �pproval of the completed Back�.valer Prevention Device rebate package by lhe City ot Everett I <br /> � <br /> C�—"U'�-4,.�'_ ' G��a.�-�� _ C/ �1J (S� -- i <br /> Signature of Contractor Date � <br /> � <br /> ! <br /> i <br /> , <br /> i <br />