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, <br /> . ! <br /> � <br /> I <br /> i <br /> i <br /> I <br /> •- Contractor Section: . : <br /> I <br /> ------- ; <br /> �.i�.i'�T-� -- �- �.. � .c •.'L,1 LLG__.�ci'� ;,c�.:�:3 i <br /> Vendor Name I Busine,s Name/UBI Number � <br /> i <br /> i <br /> Q NI � ��T `��-�3 ��K�-�' - ------ - ' <br /> State of Washington Contractor License Number. ' <br /> ; <br /> _�(P La.cl�►_►��1P , u�,�f' _t,�.����,X�os3 <br /> Vendor Mailing Address City Stale Zip ; <br /> i <br /> a�-�:n-- �g� L�����Lc�.�. ��>� �����i-r�_ i <br /> Phone Email <br /> I, lhe Vendor, a�ree to receive the Backwaler Prevention Device rebate check direclly inr the ` <br /> inslallation at lhe above referenced property adaress. By agreeing to receive lhe re6ata check I <br /> directly, I agree to the (ollowing: � <br /> I <br /> 1. The Backwater Prevention Device rebate amount wili be deducted from the final invoica i <br /> given to the property owncr for the installalion at lhe properiy address referenced above, if i <br /> the tolal cosl of the installation is grealer Ihan lhe rebate. j <br /> 2. I, the Vendor, am a Washington State licensed coniractor. <br /> 3. The City of Everelt�vill send a Federal Form 1099 MISC to me, Ihe Vendor, For Backwafer <br /> Prevenlion Device robate paymenls rotalin� more fhan $600 per catendar year, and will ; <br /> report the same payments to the Inlemal Revenuo Service. � <br /> - — - ---- —— -- ---- - -- � <br /> I accept the paymenl of the Backwater Prevenlion Davir.o rebate from the Ciry o(Everett pending ; <br /> approval of the compieted Backwaler Prevenlion Device rebale par.kage by the City of Everett � <br /> i <br /> i <br /> I <br /> �� �� �� / � <br /> (�C-r-�-"�----�.�-t�-=r'--�-------- -� �D I�S I <br /> Si�naWre of Contrar,tor Date � <br /> ; <br /> - _ _ - ---- � <br /> ----- ---------.—_--------- -- - <br /> E <br /> i <br /> f <br /> i <br /> � <br /> . ! <br />