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i <br /> I <br /> I <br /> , <br /> � <br /> � <br /> � Contractor Section: <br /> A���/a �'��..,�3r.,.s ��3 0/3 osbi <br /> Vendor Name I Business Name I UBI Number <br /> =�A � �31,T _ _.— <br /> Stale of Washington Contractor License Numher. <br /> _C6r.7 7/s'f?vE n/r na.-ps✓ iic i �► ��Y+ � <br /> Vendor Mailing Address City State Zip <br /> ' - G�cr ��4'D,S� 3�� /So) <br /> iPhone Email <br /> � <br /> I, lhe Vendor, agree to receive the Backwaler Prevention Device rebale check directly for ihe � <br /> installalion at the above referenced property address. By agreeing lo receive the rebate check <br /> direcli�, I agree lo the following: <br /> II <br /> 1. The Backwater Prevenlion Device rebate amount will be deducted from the final invoice <br /> given to the property owner for the installalion al the pioperty address referenced above, if <br /> the total cosl of the installation is greater than the rebate. <br /> 2. I, lhe Vendor,am a Washiny;on Slate licensed contractor. <br /> 3. The City oi Everett will send a Federal Form 1099 MISC to me, the Vendor,for Backwater <br /> Prevention Device rebale paymenls totaling more than $600 per calendar year, and will <br /> repoR the same payments to the Inlemal Revenue Service. <br /> I1 accepl the payment of the Backwater Prevention Device rebale from the City of Everett pending <br /> approval of the completed Backwaler Prevention Device rebale packaye by lhe Cily of Everetl <br /> i <br /> � !/z//is'' <br /> Signa�ure of Conlractor Dale <br /> ; <br /> � <br /> � <br /> � <br /> � <br /> i � <br /> ' --__ __-- —---- -- — <br />