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. � <br /> I <br /> i <br /> � <br /> Contractor Section: � <br /> : <br /> ------ ' � <br /> �4����1�-�-��lG—��• �> 'iC�,>�'t-�"L�C:�:=�CL'�k3�.3 � <br /> Vendor Name 1 Busine s Name 1 UBI Number <br /> i <br /> ��1_��z-���_K-�- - -- I <br /> State of Washington Coniractor License Number: � <br /> .��v�_[� ��►`i—�= Et✓e���1f—���'��_ ; <br /> Vendor Mailing Address Ciry Slate Zip ! <br /> 0�4,-��•_�?L4,� G�'�clttLc.�'._3�3 <<�s.c���'12_ � <br /> Phone Email , <br /> � � <br /> _ i <br /> I, the Vendor, agree to receive the E3ackwater Prevention Device rebate check directty for lhe � <br /> ^stallation at Ihe above referenced property address. Ry agreeing to receive ihe rebate check <br /> .�recUy, I agree to the following' i <br /> 7. Thc Backwater Prevention Device rt �ate amount v�ill be deducted irom lhe(inal invoice � <br /> given lo the property ow.ncr for Ihe installation at the property address �eferenced ahove, if ; <br /> the rotal cost of lhe installalion is greater ihan the rebate. , <br /> 2 I, the Vendor, am a Washington State licensed contraclor. <br /> 3. The Ciry o(Fvcrelt witl send � Federei Form 1U99 MISC lo me, Ihe Vendor,(or Bar.kwaler j <br /> Prevention Devico rebate payments totaling more Ihan $G00 per calendar year, and will � <br /> report the same payments to Ihe Inlernal Revenue Service. � <br /> - - - ---- ' <br /> — --— -- -- -- - � <br /> 1 accept the payment of the Backvr:+ter Prevention Device �e6ale trom ihe City ot Evcrelt pending I <br /> apV���al of Ihe completed Backwater Prevention Device reh;ile package by the Cdy ot Everefl � <br /> � <br /> � <br /> ���%�'�' - --��/� ' <br /> Signa�ure oi Cont�actoi Date � <br /> i <br /> � <br /> i <br />