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,.r� � <br /> � , . <br /> _ { <br /> , . <br /> - � ,� r � <br /> , <br /> Contractor Section: <br /> ��i��7L5 Iv`��Va,"� r �'/���l'l/�-y �y d 7. "7 J� '�, ! � <br /> Vendor Name/B�rsiness Name/UBI Number <br /> i 7�L'l v l�'o//i"'J <br /> State of Washington Contractor License Number: ' <br /> t` �C // L�l��"'a w�����u� �'h� ��--r- i,ur� 9��'v <br /> Vendor A4ailing Address City State Zip . <br /> / 2 5- 2,1� 3 t 1 z3 _ �gr�Al��,1�n2�� ��7-� `7� �'� l . <br /> � <br /> Phone Email <br /> I,the Vendor, agree lo receive the Backwater Prevention Device rebate check direclly(or the <br /> installaBon at ihe above refere�ced properry address. By agreeing to receive the rebate check <br /> directly, l agree to the following:' <br /> 1. The Backwater Prevention Device rebate amount will 6e deducted from the Mal invoice <br /> fliven to the property owner for lhe installation at the property address referenced above,if <br /> the total cost oT the installalion,is greater than.the rebate. <br /> 2. I,the Vendor, am a Washi�:gton State licensed wnVactor. <br /> 3.. The City of Everell will send a Federal Form 1099 MISC to me,lhe Vendor,for Backwater. <br /> Prevention Device rebate payments tolaling more than$6C0 per calendar year, and will <br /> repoA lhe same payments to the Intemal Revenue Service. <br /> 1 accept Ihe payment of lhe Backwater Prevention Device rebate from the City oF Everett pending <br /> approval of the cornpleted Backwaler Prevention Device re6ate package hy the City of Everett <br /> ��- 15 i �:- <br /> Signa)ure of Contractor Dale <br /> , ;;; <br /> ,. � <br /> �, <br /> . . . „��,..,n ..t'�: <br /> . . . . . �'�t_ <br />