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� <br />Contractor 5ection: <br />�Po�/a /�/u-.� d, � � l�3 0%3 � <br />Vendor Name / Business Name / UBI Number <br />1�ao//p/ �G 3 GT <br />State of Washington Contractor License Number: <br /><cio� 7�� A�G Nl ..-,��YSv;i�c 1N9 __ _�ff��i _ <br />Vendor Mailing Address City State Zip <br />C/LS� '3��� /Sc�7 _ <br />Phone Email <br />I, the Vendor, agree lo receive the Backvraler Prevention Device rebate check directly for the <br />instailalion at the above referenced property address. By agreeing to receive the rebate check <br />directly, I agree to the following: <br />I 1. The Backwater Prevention Device rebate amount will be deducted from the final im�oice <br />given lo the property owner for lhe inslallation at the property address referenced above, if <br />the total cosl of the installalion is greater lhan the rebate. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. The City of Everelt v✓ill send a Federal Form 10y9 MISC to me, the Vendor, for Back�vater <br />1 Prevenlion Device rebate paymenls lolaling more than 5600 per calendar year, and will <br />report thc same payments to lhe Internal Revenue Service. <br />i accepl the payment of the Backwaler Prevenlion Device rebate from lhe City o( Everelt pending <br />approval of Ihe compleled Backwater Prevenlion Device rebale package by lhe City of Everett <br />Signature of Contractor <br />i-- — _ _- -- <br />1 /�.t/i� <br />Date <br />