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i <br /> , I <br /> . ; <br /> Contractor Section: <br /> ( <br /> — — -- � <br /> I - , - ii'IC'� °�? �'�.%�c,�a`` ��— �'���'/i�� ; <br /> Vendor Neme/Business IJame/ UBI Num er ! <br /> r��jO.S ���_� ; <br /> State of Wa�shington Contra or I.icer,se Number: ; <br /> - a3 -�3�-��� 5( �1� f�7r�,�E< r,�? c�'�,� ; <br /> Vendor Mailing Address City State Zip � <br /> � <br /> ?��G/G�' Lfl�f3 /�Lx��-�e�lt.Yn������s���r cc �j:��:;/, c�,,,� ; <br /> Phone Email � <br /> i <br /> I,the Vendor, agree lo receive the Backwater Prevenlion Device rebate check directly for the � <br /> inslallation at ihe above referenced properly sddress. By agreeing lo receive the rebafn rtie^� ; <br /> direclly, I agree to the following: ; <br /> 1. The Backwaler Prevention Device r�=bate amounl will be deducted from the final invoice � <br /> given to Ihe property ownar for Ihe instaliation at ihe prcperty a�dress referenced above, if <br /> the total cost of Ihe instaliation is greater lhan the rebate. <br /> 2 I, ihe Vendor, am a Washington State licensed conlractor. <br /> i <br /> 3. 7he City of Everetl will send a Federal Form 1099 MISC �o me, lhe Vendor, for Backwaler <br /> Prevention Device rebate payments lolaling more Ihan 5600 per calendar year, and will <br /> report the same payments to the Internal Revenue Service. � <br /> 7 <br /> I accepf Ihe payment of the Backwaler PreveNion Device rebate from the City of Everett pending � <br /> approval of fhe completed Backwaler Prevontion Device r�bale package by the Cily of Everelt <br /> ` r `�"9 — — �� ��� i <br /> ; <br /> Sign lure o(Conlracfor Dale i <br /> --- — � <br /> I <br /> I <br /> ! <br /> i <br />