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Contractor Section: <br />Motr� PI�..�h; <br />Veridor Name I Business t�ame / UBI Number <br />M v en ��� .� � 3� O <br />State o( Washington Contractor License Number: <br />��� ��� �K <br />i�7 S 1 S �'� �� S�, s� �.��^�-t S� �- / s2�1C� <br />Vendor Mailing Address Cily State Zip <br />��. S %� 0 �l�i� <br />Phone <br />T� <br />Email <br />; �„�: ccr� <br />I, the Vendor, agree lo receive the BacFwater Prevention Device rebale check directly for the <br />installation at lhe above referenced property addre,s. By agreeing to receive the rebate check <br />directly, I agree to the tollowing: <br />1. The Backwater Prevention Device rebate amount wiil be deducled from the final invoice <br />given to lhe properly owner for the installaiion at the property address referenced above, if <br />the total cost of the installalion is greater lhan the rebata. <br />2. I, lhe Vendor, am a Washington State licensed contractor. <br />3. The City oF Everett avill send a Federal Form 1099 MISC to me, the Vendor, for Backwaler <br />Prevention Device rebate payments totaling more than $600 per calendar year, and will <br />report the same payments to the :ntemal Revenue Service. <br />I accepl ihe payment of the Backwater Prevention Device rebale irom the City of Everett pending <br />approval of the completed Backwater Prevention Device rebate package by lhe City of Everett <br />C" ,1 �% M ^' <br />/' J C�- <br />Signature of Contraclor <br />�—"�v—IS <br />Date <br />