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CoMrector Sectlon: <br />Vendor Nome / Buslnoss Name / UBI Number <br />ts-,�- �l�l�o �� Pn � <br />State of WasAington Contractor License Number: <br />�(O !1 (/I,S ta ✓2 s� �- -�-„�zr <br />Vendor Mailing Addiess Ciry Stale Zp <br />� L/�Jq—U%2"3 R-,v-O��f^r�f�r <br />Phone Email <br />I, tha Vendo�, agree lo receivo ihe Backwaler Prevenlbn Devbe rebate chock diredly fw lfie <br />instanauon at the ahove referenced property address. ey agreeing to receive the reb��te chedc <br />diredy, I agree to the following: <br />1. Tha Backwater Prevenllon Dovice rebate amount wiU be deduded from ihe Mal InvWce <br />given lo Ihe propeAy owner for lhe Instellelion el 1he property address roferenced abovo, If <br />the toql cost oi tha inctallation Is grEaler thar, ttw rebate. <br />2, I, the Vendor, am a Washington State Ilcensed contredor. <br />3. The City of Everelt will send a Federal Fortn 1099 MISC lo me, lhe Vendor, fw Backwater <br />Preventbn Devloe rebate peymenta tolalinp moro Ihan 5600 per calender year, and vnll <br />repo�t tlia same payments to the Intomal Revonue Servica. <br />I aaxpl tlio peymonl of Ihe Badcwater Pteventlon �evice rebate from the Cfty of Sverett penuing <br />approvel of Ilie rnmpieted Backwaler Provenlion Device rebate padeage by the Clty ai Evoietl <br />–��� /a a-�/� /S— <br />SignaWre of Contractor Date <br />