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Contractor Section: <br />� 1 J'�— `7�: . ����.. `,��tc�'l', LL-C.� _�%'-�3���: <br />3-!' �''i.�ct <br />Vendor Name 1 Busine s Name! UBI Number <br />_�.I_'IF.,��S_`� �L_�� <br />State of VVashinyton Coniraclor I_icense Number. <br />�� L�a.r.__�� <br />Vendor Mailing Address <br />Phonc <br />Email <br />City State Z�P <br />I, ihe Vendor, agree to receive the Backwater PrevenGon Oevice reba(e check directly for the <br />installation at fhe above reterenced properly address. 3y agreeing to receive the rebate check <br />directly, I agree to ihe tollov:ing: <br />1. i he Backwater Prr.vontion Device rebate amounl will be deducled from the f nal invoice <br />given lo the property o�vner for thc installation al lhe propeRy address referenced above, if <br />lhe total cost of the inslalla�ion is grealer Ihan ihe rehate <br />�. <br />I, the Vendor, am a l0.'ashinglon State licensed contractor. <br />The City �f Everett will serid a Federal Form 1099 �41SC to me, lha Vendor, for 8ackwater <br />Prevention Device rebate payments tot2lin� morn than $600 per calendar year, and will <br />report �he samc payments to the Inlernal Revenue Service. <br />I ar.cepl Di� P�Y��enl oi lhe 8ackvraler Prevention Device rebate from Ihe Cily of f=veretl pending <br />approval of lhe completed dackwater P�evenlion Device �ebale package by the City of Fverett <br />I � �_ <br />, C���. �.�.� - <br />� SignaWre of Conlractor <br />I--- - <br />_ _����//5 -- <br />Oate <br />