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i <br /> � <br /> , <br /> I <br /> j <br /> Contractor Section: . ; <br /> --- --- ' <br /> /, i <br /> i��i'aiC1�1�-`�t'�?{"-ct'—�f�.�r`_�--� 'tc, '-i�=G,�' (u!r 3 ;3�I�.�3 <br /> Vendor Name I Busine5s Name/U81 Number <br /> _9�_�P�S.��-�---�-�- ---- - <br /> Stale of Washington Contractor License Number. <br /> �oio La r_1�11 t� 2,. �t��r�- ' _(.��—�i'�;�G3 : <br /> Vendor Mailing Address City Stale ZiP • <br /> a��-��sa ����+i��� t%��(�����._ � <br /> Phone Email <br /> I,the Vendor, agree to receive the Backwaler Prevention Device rebate chec<direcUy tor ihe <br /> installation at the above referenced properiy eddress. By agreeing lo receive thc rebale check <br /> direclly, I agree to the following: ' <br /> 1. The Backwaler Prevention Device rebate amount will be deducted from tne final invoice <br /> given to the property owner for the installation at the property address referenced above, if ; <br /> the totai cost of the installalion is greater lhan Ihe rebate. <br /> 2 I,tho Vendor, am a Washington Stale licensed rnntractnr. <br /> 3. The City of Everett will send a f'ederal Form 1099 ti�ISC to me,lhe Vendor, for f3ackwater <br /> Prevention Device rebate paymerts totaling more than$600 per calendar year, and wili <br /> report the same paymenis to the Inlernal Revenue Service. <br /> I accepl lhe payment of the Backwalor Prevention Oevice rebate from the City of Everett pending <br /> approval of the completed Backwalei Prevention Device rebale package by Ihe City o(Everett <br /> , <br /> � � 1-�/��—_ <br /> i • Y1 <br /> �e ac...-( - _���� _ —�-k�" � <br /> Signature ot ConUacror Date ' <br /> I <br /> -- --------- - -- ----- -- + <br /> � <br />