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i <br /> f <br /> � <br /> I <br /> i <br /> � <br /> � <br /> Contractor Section: . � <br /> 1 <br /> — ---- — - - - ------ ; <br /> I <br /> �}�'�C11���L'_{_�'�cC�.•�; ' `� °ct?�f� LL•C� _..C;�;�'� ; �.y.�'3 , <br /> Vendor Name! Busine�s Name 1 UBI Number � <br /> I <br /> � <br /> H ��-I����—�Y <br /> Stale of Washington Contractor License Number: <br /> { <br /> _���L9l�:i►�\—Q��._.�4_✓�C��-1.��_�t'�a�� i <br /> Vendor Mailing Address City State Zip i <br /> � <br /> �,�-;�-rt�� �ga C����ic-�._a:�:�����1���22 ' <br /> Phone Email <br /> i <br /> I, the Vendor, agree lo receive the Backwater Prevention Device rebate check direcliy for the <br /> instailation at Ihe above referenced properiy address. By agreeing to receive the rebate chec!: i <br /> directly, I agree to Ihe following� � <br /> 4 <br /> 1. The dackwater Prevention Device rebate amount will be deducled irom the 6nal invoice <br /> given !o the prope�ly owner for the installation at lhe properiy address referenced above, if ; <br /> the total cost of the instailation is greater than �he rebate. ; <br /> 2. I.the Vendor, am a Washington State licensed contractor. <br /> 3. The City of Everett will send a Federal Form 1099 !v11SC to me, the Vendor, fnr Backwater i <br /> Prevention Device rebate payments totaling more than $600 per calendar year, and tvill � <br /> reporl the samr, payments to the Internai Revenue Service. i <br /> i <br /> I accepl the payment of tho Backwater Prevention Devic�: rebate from lhc Ciry of Evarett pending I <br /> approval of the corn�leted Backwa[er Preven�ion Device rebate package by Ihe City ot Everelt � <br /> i <br /> � ' <br /> ��� � ���,,,,_�l � k <br /> `�"" {c.''L-_�--'<="'. '`��------ � i <br /> Signature of Contractor Date i <br /> i <br /> i <br /> I <br /> ! <br /> � <br /> I <br /> i <br /> � <br />