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Contractor Sectinn: <br />c- � <br />� C"�: u � r r� - 2 i�� 1 ��,s <br />Vendor Name I Business Name 1 UBI r <br />�C'.W�� -� �—��� LC� YY'� <br />L I� C " v 0', vl ��`� <br />ber <br />State of Washington Contractor �icense Number. <br />�r� �x �-1-15 ��r, <br />Vendor Mailing Address <br />City <br />�jg'��}� <br />Zip <br />_�lo S';'IU -1�-} i � �!,<<i�.L���e•.�veY-{riChC��V,C�� I <br />Phone Email I <br />--- — � <br />I, th� b'endor, agree b receive the Backwater Prevention Devic= rebate check directly for ihe <br />installation ai Ihe a9ove referenced properly address. By agreeing to receive the rebate check <br />direclly, I agree to the following: <br />1. The Backa�ater Prevention Device rebate �mount will be deducted from the final invoice <br />given to the property or;ner for thc install2tion at the property address referenced above, if <br />lhe total cost of lhe installation is grcater lhan the rebate. <br />Z. I, the Vendor, am a Washington Slate 6censed conlractor. <br />3. The City of Everett �vi�l szrd a Federal F�rm 1059 MISC' to me, ihe Vendor, for Backw;ter <br />Prevenlion Device rebat= payments totaiing more ih2n 5600 per calendar year, and r:ill <br />reporl Ihe same payments to the Iniernal Revenue Service. <br />r-- ---- -- --- --- -- --, <br />I accept ihe paymenl of the Backwater Pre��ention Device rebate 6om the City of Everett pending <br />approval of lhe comp!eted Backwaler Prevention De�ice rebate package by the City or Everett <br />� <br />'_%G''�����-G_��c.... (�.F^ _ <br />� <br />Signature of Contractor Date i <br />-------------- -- -- - _ _ - - -- - -- � <br />