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i <br /> ! <br /> ; <br /> � <br /> i <br /> � <br /> Contractor Section: � <br /> i <br /> � �"luc',� I� IUn�,� � ��y [. LL LG3 - `-f(�3- fs(v `� � <br /> Vendor Name/Business Namd�UBl Number � <br /> Mv� PP-�` �'�S ;)� i <br /> State o`Washingion Centractor Licensa �umbec ! <br /> _ 1 7S iS y�°t� s� SL"' Sn�Ho+�,rt�. �✓k� �=t�z.9U `• <br /> V�ndor ibiailing Address Ciry State Zip ; <br /> i <br /> � c-1;2f 7�u ���c) ��^�,n� Ci r�-icc'.n f%la,.^h%�1 c,o-. <br /> I uhono Email � <br /> � • <br /> - ----- — �__—J <br /> I, the Vendor, agree to receive the Bacl��vater Frevention Device rebate chec't duectly for the <br /> installation at Ihe abcve referenced prooerty address. By agreeing to receive ihe rebate check <br /> direct y, I agree to the follovr:rg: <br /> f <br /> 1. The f3ackwaler Prevention Device rebaie an•�ount tivill be deducteJ from the Enal invoice <br /> give� to thc property owner fcr lhe installalion at the property address referenced above, if <br /> If�e total cost of the ins,allation is grr.ater lhan thc rebale. ! <br /> 2 I, tha Vendor, am a Washington State licc;nsed contractor. <br /> 3. 1 he City of Evcrett�vill send a Federal Form 1099 i1915C to me, ihe Vendor, fur 6ack�vater • <br /> Prevention Device reLale payments totaling more lhan 56U0 per calendar year,and will � <br /> report thr same payments to fhe Internal Revenuc Service. � <br /> II accept the payment o(the Baclnvaler Prevention Device rebatc from the Ci,y oi Everelt pending <br /> �' approval nf the completed Backwater PrevenGvn Device rebate packoc�e by the City of Everelt ; <br /> � <br /> i <br /> i . _� � <br /> � ._ ��`��-�Z��, � -� I- r S' � <br /> o�cnature nf Contracfoi Dale , <br /> �--r--------- ' <br /> i <br /> � <br /> i <br /> � <br />