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i <br /> , <br /> � <br /> ; <br /> ; <br /> Contractor Sectian: ! <br /> I <br /> —_ — I <br /> l� u�,� I� Ic�Mh ��� � LG C�d3 �- '-( (�3— 7�(,G� ; <br /> Vendor Name!Business Nam 1 U61 Number ! <br /> i <br /> M u�r V P i` �sS �v ' <br /> Stafe of Washinglon Contractor License Number: <br /> ( 7S i5 41�r sd SG' Sn�i�o�n���� w�1- 4�L�v ! <br /> Vendor Mailing Address Ciry Stale Zip i <br /> `1r�� 7bU �1�U .— 1 �`'nb� C� Mo��lu.•�Gi��ay.c_c.:�. ` <br /> _ � <br /> Phone Email <br /> � <br /> --- ; <br /> -- - i <br /> i,the Vendor, agree to receive lhe Backwater Prevention Device rebate check directty for the � <br /> inslal!ation at the above referenced property address. By agreeing to receive the rebate check • <br /> directiy, I agree to lhe followiny: <br /> 1. Tho Backwater Prevenlion Device rebate amount will be deducled from Ihe final invoice <br /> given lo the property owner(or tho inslallalion at the property address reterenced abovo, if <br /> the iotal cost of the inslallatlon is c�reater lh�n the rebate. <br /> 2. I, lhe Vendor, am a Weshington Stale licensed contractor. <br /> 3. 'fhe City of[verelt will send a Federal Form 1099 MISC to me, Rie Vendor, for Backwater � <br /> Prevenlion Device rebate paymenls lotaling more than 5600 per calendar year, and will ' <br /> repori lhc^,amc paymeMs to the Intcrnal Revenuo Service. ' <br /> i <br /> I accept Ihe payment of the dackwater Prevenlion Device iebate from the Cily ol Fvereit pending � j <br /> ❑pprovol of 1he completed Backwater Pra��ention D�vice rebato package by Ihe City uf Everelt � <br /> ' <br /> i <br /> _ `"�� � ' �-�� -r t ! <br /> ISignalute o(Conl�aclo; Date � <br /> �_ <br /> ; <br />