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Contractor Section: <br />Vendor Name / Business Name ! UBI Number <br />�Mz F, �S� �o ► K� <br />Stale of Washington Contraclor License Number: <br />�>f'�t7v l-crl�� ll�� iEt�'f�" I,�fl ��.i� <br />Vendor Mailing Address City State Zip <br />`�7n- �p . �r:R�l �'�;��c.�C IY1�',r`� eeeyn��v��%� ,r' �CdJ79 <br />Phone Email <br />i <br />I, the Vendor, agree to receive the Backwater Prevenlion Device rebate check directly for the <br />installation at the above refrrenced prbpeAy address. 8y agreeing to receive the rebate check <br />direcUy, I agree to ihe following: <br />1. The Backwater Prevention De�ice rebale amount will be declucted from the final invoice <br />given to the property owner for the installation at the property address referenced above, if <br />tha total cost of Ihe installation is greater than lhe rebate. <br />2. I, lhe Vendor, am a Washingron State licensed contractor. <br />3. The City of Everett will send a Federal Fortn 1099 MISC to me, the Vendor, for Backwater <br />Prevention DeviCe rebale payments totaling more lhan $600 per calendar year, and wili <br />report the same payments [o ihe Intemal Revenue Service. <br />I accept the payment of the Backwater Prevention Device rebale from the Ciry of Everett pending <br />approval of ihe completed Backwater Prevention Device rehate package by �he City of Everett <br />.�Bj�� ' �i�.+�� � � � <br />Signature of Coniracror Date <br />