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r � <br /> ' � <br /> � <br /> i <br /> i <br /> � <br /> • Contractor Section: i <br /> i <br /> � � � � � M `-�i`��. �(�ic�'� LLG (�;c��� ,���3 ' <br /> Vendor Name I Busine s Name!UBI Number I i <br /> A ivi � �'T �� �t i,� ! �L-_ � �' <br /> State of Washington Contractor License Number: � <br /> �(�C�lo LQ,(' �►1� n P��____��/�'1������G� ` ' <br /> Vendor Mailing Address City State Zip � <br /> ; <br /> Ar� -�=1D��n ga C'�nc1� (' i c:� ����•J��oR•�'_��j22_ ' <br /> Phone Email � <br /> I <br /> ( <br /> _ � <br /> I, the Vendor,agree to receive the Backwater Prevention Device rebate check directly for lhe i <br /> installation at the above referenced property address. By agreeing to receive the rebate check � <br /> directly, I agree to the following: � <br /> 1. The Backwater Prevention Device rebate amount will be deducted irom the final invoice � <br /> given to the property owner for the instailalion at the property address referenced above, if � <br /> the tolal cost of the installation is greater than the rehate. � <br /> 2. i, ihe Vendor, am a Washington State licensed contractor. ' <br /> 3. The Ciry of Everett will send a Federel Form 1099 MISC to me, the Vendor, for Backwater ! <br /> Prevention Device re:�te payments totaling more than $600 per calendar year, and will � <br /> report the same payments to the Internal Revenue Service. ; <br /> — -- I <br /> I accept the payment of the Backwaler Prevention Device rebate from the City of Everett pending ; <br /> approval of .�•�completed Backwater Prevention Device rebate package by ihe City uf Everett J <br /> ( <br /> j <br /> i <br /> �.�..�.� � �r.,.� _ �b � , ,� � <br /> i <br /> Signature of Contractor Date ; <br /> { <br /> i <br /> � <br /> � <br /> � <br /> i <br /> S <br /> � f <br />