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Contractor Section: <br />Itj(a LLC. <br />- y(03- 5rc;Ct <br />Vendor Name I Business NamW1 UBI Number <br />Moe,-, PGf j�j,,�37J <br />State of Washington Contractor License Number: <br />[75 I S 41`r Sd 5nzko.+,rc to`1b2-,o <br />Vendor Mailing Address ` ,City State Zip <br />76C) D NCO �i<�0 C MCC/ln�(wM�7r�i .4L�1 <br />Phone Email 1 <br />I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <br />installation at the above referenced property address. By agrer ing to receive the rebate check <br />directly, I agree to the following: <br />1. The Backwater Prevention Device rebate amount %.*.ill be deducted from the final invoice <br />given to the property owner for the installation at the property address referenced above, if <br />the total cost of the installation Is greater than the rebate. <br />2. I, the Vendor, am a Washington Stale licensed contractor. <br />3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br />Prevention Device rebate payments totaling more than $600 per calendar year, and will <br />report the same payments to the Internal Revenue Service, <br />I accept the payment of the Backwater Prevention Device rebate from the City of Everett pending <br />approval of the completed Backwater Prevention Device rebate package by the City of Everett <br />Signature of Contractor Dat� <br />