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i i <br /> , <br /> I <br /> � Contractor Section: <br /> � I <br /> I <br /> � <br /> I f��1/�,��lu/�j��v�� �_.�_G� GS� � <br /> Vendor Name I Business Name I UBI Number , <br /> � I�GL L ��� 7 � <br /> � - -- - - i <br /> I State oi Washington Contraclor License Number: <br /> �! SL/�7/sr � n/_F. _ rarysv���� w.f 9��� � � <br /> i Vendor Mailing Address City State Zip 1 <br /> � <br /> I _�SI �J � SG � I <br /> � Phonc Email ' <br /> � <br /> � <br /> � - -- - <br /> I I,the Vendor, agree to receive lhe Backwater Prevention Device rebate check direclly for lhe <br /> installalion at the above referencea property address. By agreeing to receive the rebate check <br /> I directly, I agree lo the following: <br /> I 1. The Backwater Prevention Device rebate amount will be deducted from lhe finai invoice <br /> given to lhe property owner for the installation at the properly address re(erenced above, i( <br /> I the totai cost of the installation is c�reater than the rebale. <br /> 2. I,the Vendor, am a Washington Slate licensed cor!racbr. ! <br /> I3. The Cily of Everelt will send a Federal Form 1099 MISC to me,the Vendor, for Backwater <br /> � Preventio�Device rebate paymenls totaling more than 5600 per calendar year, and will I <br /> reporl ihe same paymenls to the Internal Rev��nue Service. <br /> I — --- — - — <br /> � - <br /> � I accepl lhc paymenl of the Backwater Prevenlion Device rebate from the Cily of Everefl pending <br /> approval of the completed Backwater Prevenlion Device rebate package by Ihe City of Everetl <br /> I I <br /> � z7l�� <br /> Signature oi Contractor Date <br /> � <br /> I <br /> �1 <br />