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Contractor Sectio��: <br />r'�b�Trs %� �Iv�.-� �-�l�.�h,r�4 �0�-��2 ��3 <br />Vendor Name / Business Name I UBI Numh�r <br />_�N4-p��L� 6i/PD <br />State of Washington Contractor License Number <br />_� h// (/l 1 t�+VQiytu f9�� t ��-`rl_ �1,�!_ n��L' <br />Vendor Mailing Address Cily State Zip <br />��I 8�-0 (Z 3 i4r4- ,o/�.-,� hin� /1 ��-!� C-� Gm <br />Ptione Email <br />I, the Vendor, agree lo receive the Backwaler Prevention Device rebale check direclly (or the <br />installation at the above referenced property address By agreeing to receive Ihe rebate check <br />directly, I agree to the following: <br />1. The Backwater Prevention Device rebale amount will be deducted (rom ihe final invoice <br />given to the property oemer for the installation al lhe property address referenced abovr„ ii <br />the rotal cost of the instailation is greater than the rebate. <br />2. I, lhe Vendor, am a Washington 5tale licensed conlractor. <br />The City o( Everelt will send a Federal Form 1099 h41SC to me, lhe Vendor, for Backwater <br />Prevention Device rebate payments totaling more than $600 per calendar year, and will <br />report lhe same paymenls to ihe Internal Revenue Serv�ce. <br />I accept lhe payment of the Backwrater PreveNion Device rebate from lhe Cily of Fverelt pending <br />approval of the comp�eted Bachwaler I�revenlion Device rebate package by the Ciry of Everell <br />'�`_''V_ _����� <br />Signature of ConUaclor Date <br />