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Contractor Section: <br />�i?,.I.G�"L�.��l��n/� I�J —G/� —USS� <br />Vendor Name / Business Name ! UB� Number <br />��L PL 9� � [; i <br />State of VVashington Coniractor License Number: <br />5`�G7 7/5'/�Vr NL MAIZYSVi/1_�� WR �it:z70 <br />Vendor Mailing Address City State Zip <br />�"l?S� 3�si ''L�so7 <br />Phone Email <br />I, the Vendor, agrPe to receive the Backvaater Prevention Device rebate check directly tor the <br />inslallation at tho above referenced property adoress. By agreeing to receive the rebate check <br />directly, I agree to the following: <br />1. The Backwaler Prevenlion Device rebate amount will be deducted from lhe final involce <br />given to the property ormer for the installation al the property address refererced above, if <br />the total cost of the installation i; greater than the rebate. <br />2. I, the Vendor, am a �4�ashington State licensed contrac�or. <br />3. The City of Everett will send a Federal Form 1099 NISC tc me, the Vendor, for Backwater <br />Prevention Device rebale paymeMs lotaling more than $600 per calendar year, and will <br />report lhe same paymenis to the Internal Revenue Service. <br />I accept Ihe payment of the Backv,�ater Preveniion Device rebate from the Clty of Everett pending <br />approval of ihe completed Backwater Prevention Device rebate package by the City of Everett <br />Signature of Contractor <br />3 z /�y.,/ <br />Date <br />