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� <br />�e <br />Contractor Section: <br />�-11��'t �GJ� <br />� <br />Vendor Name ! <br />Name / UBI Number <br />_�/ 1�'���-� ("rZL _�-�- - <br />State of Washingion Contractor I_icense humber. <br />-'.�� Z�t�3 <br />b�W3"i� �-41`�.i�i–���_�Z✓�'if�� �!�i_—_�.����. <br />�iendor Mailing Address Ciry S!ate Zip <br />� Phanc <br />I�----�-- <br />i'�i�C�� Ge��?�_ C'� ' q�l(�� CO�— <br />Email <br />I, the Vendor, agree to receive the Backtia�ater Pre��ention Device rebate r.heck direcUy fnr the <br />installa:ion at the abo��e reforenced properiy address. By agreeiny to receive the rebate check <br />dirr.ctly, I agree to the following <br />t. The Backwater Prevenlion Oevice rebate amount will be deducted imm the final invoice <br />yiven `.o lhe property ovmer for the inslaila,ion at lhe property address referenced above, if <br />tne total cest of the installalion is greater than the re6ate. <br />2. I, lhe Vendor, am a Washinqlon State iir,ensed conlraclor. <br />3. The City of Everelt will s� nd a Federal Form 1099 MISC lo mc, thr Vendor, For Backwater <br />Prevention Device rebale payments tolalin9 more Shan 5600 per caiend�r year, and will <br />report the same payments to ihe Inlemal Revrnue Service. <br />I accepl ihe payment of Ihe 8ack�vater Prevention Devic:e rebale from Ihe City of Eveietl pending <br />approval of the completed E3ackv�ater Prevenlion Devic^ rebate package by the City of Everett <br />C���_ ��� <br />Sic�n2lure of Contractor <br />-��j (�sr <br />Date <br />