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� <br /> � <br /> � <br /> � <br /> � <br /> � <br /> , <br /> I <br /> Contractor Section: � <br /> I <br /> � <br /> /�r�yl.i.0 i�L_r�Mjiivv ���.3 -�i � - cisSt i <br /> Vendor Name!Business Name/UBI Number � <br /> �y�. -� �'i 9 ; - I <br /> , � ; � <br /> St2te of Washington Contractor License Number: ; <br /> i <br /> S`/�i.7 �7/'r/¢v� �✓i. M.qIZYSily11�= W/1 9Y�70 ; <br /> Vendor Mailing Address Cily State Zip ' <br /> i <br /> �"l.?KS) �ts7 -'1�U7 � <br /> Phone Emafl ; <br /> � � <br /> � <br /> I, the Vendor, agree to recelve tne Backwatei Prevention Devioe rebale cneck direclly for ihe ; <br /> installaUon at the above referenced property address. By agreeing to receive ihe rebate check j <br /> tlirectly, I agree to the following: ; <br /> 1. The Back�ti�ater Prevenlion Device rebate amount�vill be deducted from ihe final invoice � <br /> given to the property or+ner for the installation at the property address referenced above,If � <br /> the total cost of lhe installatlon is greater than the rebate. i <br /> 2. i, �he Vendor, am a Washing;on State licensed contractor. i <br /> 3. The Clty of Everelt will send a Federal Form 1099 fv11SC to me,the Vendor, for Backe+ater � <br /> Prevention Devico rebate payments iofaling mora than$60D per calendar year,and ivili j <br /> repo�t the same payments to the Inlernal Revenue Service. • <br /> i <br /> i <br /> I accept the payment of the Oackwater Preveniion Device rebate from the Cily of Everelt pending � � <br /> approval of lho completed Backwaler Prevenlio� Device rebote package br the City of Everett � <br /> � <br /> � <br /> i <br /> y��-r/�� � <br /> Signature of Contractor Date { <br /> i <br /> � <br /> � <br /> � <br /> � <br /> � <br /> ! <br />