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Contractor Section: <br />L1--C � (�OL�I 3 5� �O <br />Vendor Name / Business Name /�UBI Number <br />�f'.W�r� L�l� lP rn j <br />State of Washington Contractor License Number: <br />� <br />I�id4 �-1� <br />Vendor Mailing Address City State Zip <br />' OCQ�i��C��- ]�� � ���til�eC;�we� �r i�ci ly,<_�om <br />. <br />Phone Email <br />I, the Vendor, agree lo receive the Backwater Prevention Device rebate check directly for the <br />installation at the above referenced property address. By agreeing to receive the rebate check <br />direclly, I agrae to the following: <br />1. The Backwater Prevention Device rebate amount will be deducted from the final invoice <br />given to the property owner for the instailation at ihe property address referenced above, if <br />the tolal cost of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. The City of Everep will send a Federal Form 1099 MISC to me, lhe Vendor, for �ackwater <br />Prevention Device rebate payments totaling more lhan 5600 per calendar year, and will <br />report lhe same payments to the Internai Revenue Service. <br />I accept the payment of the Backwater Prevention Device rebate irom lhe Cily of Everell pending <br />approval of the completed Backv+aler Prevention Devico rebate package by the City of Everett <br />�j// /�%C� ��/ <br />Signature of Contractor <br />Dale <br />