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I <br /> � <br /> � Contractor Section: <br /> � a � ��► a�� �� ����5_I l�_� <br /> Vendor Name 1 Business Name/UBI Numt;c� <br /> � � � 5 <br /> �tate�hingto�or License Number: <br /> � ���. 236��'St:S!� ►��,s— �� °(8026 <br /> i _ � <br /> Vendor Mailing Address Ciry State Zip <br /> ; 2��65- �f1�3 �����,������c� .�� u; ,C <br /> � Phone Email <br /> I <br /> � I, che Vendor, agree to receive the Backwater Prevention Device rebate check directly(or the <br /> installation at the above teferenced property address. By agreeing to receive the rebate check <br /> directly, I agree to the following' <br /> 1. The Backwater Prevention Device rebate amount will be deducted from lhe final invoice <br /> � given to lhe property owner for lhe inslallation at the property address referenced above, if <br /> Ithe total wst of the inslallation is greater than tho rebale. <br /> , �. I,the Vendor, am a Washington State licensed contractor. <br /> I3. The City ot Everefl will send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br /> Prevention Device rebate payments totalinc� more than 560D per calendar year, and will <br /> report Ihe same payments to the Internal Revenue Service. <br /> I accepl the payment of the Backwaler Prevention Device rebale trom the City of Everett pending <br /> � appreval oF lhe completed Backwaler Prevention Dovice rebste package by the City of Everett <br /> I <br /> � \� r ��6-�l� <br /> � � <br /> i nature ot Conlractor Date <br /> I -- <br /> I <br /> I <br /> i <br /> �� <br />