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r _ __ - - <br /> ' � <br /> � � <br /> i <br /> i <br /> � <br /> ( I <br /> i <br /> � Contractor Section: <br /> � <br /> � — <br /> I ff/�G/�i f�Gr.�(3e�9 �"�3 G/3 G S� <br /> I Vendor Name/Business Name/UBI Number <br /> ' /�.�/�G�.3 GT � <br /> iState of Washington Contractor License Number: � <br /> � <br /> � SL�Z— -�/'���9v� ��% �G�rYsvd/ie _�v� , �7d ! <br /> i <br /> Vendor Mailing Address City State Zip ; <br /> I i <br /> i ��� 3�37 �5�7 � <br /> � �ho�e Email <br /> i i <br /> � I, ihe Vendor, agree to 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 /> i �, <br /> i directly, I agree to lhe following: ', <br /> � 1. The Backwater Prevention Device rebate amount will be deducted from the final invoice i <br /> ' given to ihe property owner for the installation at the property address referenced above, if � <br /> the total cost of the installation is grealer than the rebate. <br /> I <br /> 2. I, the Vendor, am a Washington State licensed contractor. ! <br /> 3. The City of Everelt will send a Federal Form 1099 MISC to me, the Vendor, for Backwater ' <br /> Prevention Device rebate payments totaling more than $600 per caiendar year, and will <br /> report the same payments to lhe Internal Revenue Service. <br /> I ----- — <br /> I accept ihe payment of the Backwater Prevenfion Device rebate from the City of Everett pendiny <br /> approval of the completed Backwater Prevention Device rebate package by Ihe City of[verett <br /> �� -- �?�.3 �S <br /> SignaWre of Contraclor Dale <br />