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Ca ntractor Section: <br />n I� i <br />b �`� L i. � <br />Vendor Name I Business Nam� UBI Num6er <br />M(i[°!� ���'�` �`�j i.ji� <br />Stale of Washington Contractor License Number: <br />dS - `f (�3' SS�v�1 <br />f 75 i5 �t�`r SJ 5f� 5n�b�on,� ��� w�- �rb2�t� <br />Vendor Mailing Address City State Zip <br />�i�1'� 7�:,v <br />Phone <br />f /'<,n�' �i M o�n <br />Email <br />I, the Vendor, agree to rcceive lhe Backwater Prevention Device rebate check dlrecliy for the <br />inslallation at ihe ahove referenced property address. By agreeing to receive the rebate check <br />directly, I agree lo the following: <br />1. The Backwaler Provention Devlce rebate amount will be deducted from Ihe final fnvoic� <br />given to the proporly owner for the inslallalion at lhe property address referenced above, if <br />the tofal cost of thc ins�allation is grealer Ihan the rebate. <br />2. I, the Vendor, am a Washinglon State licensed conlraclor. <br />3. The City of Everetl will send a Federal Form i 099 MISC lo me, the Vencfor, (or Backwater <br />Prevention Device rebate payments totaling more than $600 pc�r calendar year, and wf1l <br />report the s.ime paymenis to ihe Internal Revenue 5crvice. <br />I accepl the payment of the E3ackwater Prevenlion Device rebate from the Cily of EvereU pending <br />app: oval of the cnmpk:led D•ackwaler Prevenlion Device rebate puckagc 6y Ihe Cily of EvereU <br />—c� �' ` �1'� c�—I l� <br />Si�natuie of Conlraclor Date <br />