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Corstrae2oc 5ectao�u: <br />1� �,,- � I, Ilit !h f�� �� <br />Vendor Name / Business N�r1Se / UBI Number <br />C� :� C> ��� � <br />Muen PPt �-k � i �� <br />State of Washington Contractor License Number: <br />i �5 i s �ct'�-' S!-. 5r 5,����r-„ sl. �✓IE Gy7_� u <br />Vendor Mai{ing Address City State Zip <br />�I � S '7 �� U y� <br />Phone <br />Email <br />!-� �;L'.n l���,`'l�ir�ca. co�� <br />I, the Vendor, agree to receive the Backv�ater Prevention Device rebate che�k d(rectiy tor the <br />instaliatien at the above referenced property address. By agreeing to recelue the rebate check <br />dlrectly, I agree to the following: <br />1. The Backvaaler Prevention Device rebate amount will be deducted trom the final invoice <br />glven to the property owner for the instailalion at the propert7l address referenced above, i( <br />the totai cost of lhe installation is greater than the rebate. <br />2. i, tlie Vendor, am a Washinglon Slate Ilcensed contractor. <br />3. The C(ty oP Everelt �afll send a Federel Form 1099 MISC to me, lhe Vendor, for �ackvuater <br />Prevention Dovice rebate payments totaliny more than 5600 per r.alen�iar year, and vfill <br />report the same payments to the Internal Revenue Service. <br />I accept the paymenf of the Backwater Prevention Device rebate from lho City of Everelt pending <br />approval of th� campleted B�ckwater Prevantion D�vice r�bale packagr by lhe Cily of Everett <br />,� ✓� ,,.,1 /J7Z ,�.;._ <br />�9 z;� d � <br />Signaturo of ConUaclor <br />Date <br />