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Contractor Sec°ion: <br />Vondor Na�Te I Busines�, Name I UBI Number <br />: <br />f�My % � SS�lo I Ki <br />State o( Washington Conlractor License Number: <br />�ar�cYo l��zrl�n.�.. �ir�t.f' l�fl G��.�:3 <br />Vendor Mailing Address City State Zip <br />l�u-a4F���" r" /�„`� /1 -�i Gl � . 1 CLL' � % ��' <br />Phone Email <br />I, the Vendor, egree to receive lhe 8ackwater Prevention Device rebale check direclly for the <br />installation at the above referenced prbperty address. By 3greeing to receive the rebate checic <br />direcUy, I agree lo lhe following� <br />�. The Backwater Prevention De � ice rebate amounl will be deducted from the final invoice <br />given lo the property owner for• lhe ins[allation at the property address referenced above, if <br />Ihe lotal cost of the instailation`_is greater than the rebale. <br />2. I, ihe Vendor, am a Washington 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 reba�e payments totaling more than $600 per calendar year, and will <br />report the'same paymenls to the Intemal Revenue Service. <br />I accep� �he payment of the Backwater Prevention Device re6ate from the City of Everett pending <br />approval of Ihe wmplefed Backwaler Prevenlion Device rebate package by the City n( Everett <br />�� �' <br />Signature of Contractor <br />la-/n-/ ¢ <br />Date <br />