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ContractorS.:ction: <br /> � /`'�u.� I�l�,M/�;y,�--- �O D�– _ ��cL -�c�� — <br /> i Vendor Name/ Busines Name/UBI Number <br /> � / '"(�7C1� ��� k. ��3 TQ _ <br /> State of Washington Contrac!or License Number: <br /> , . , , ' ; � <br /> f � S i s ��Sfsf Sr . �;.,� <br /> Sh.�:r,s� � �t�Z4 0 <br /> i <br /> - Vendor Mailing Address City. State Zip , ;�. , � <br /> ' R �S -7Go S3Gv ��-c.i� (u !`tu�n Q�ur-.�, ,�� , . <br /> , ; ` Fhone Email _ ' .. 1 <br /> f i <br /> � � _ <br /> - � . . _ ; :;• <br /> ' I, the Vendor, agree to receive(he Backwater Prevention Device rebate check directty for the ; <br /> installation at the above referenced property address By agreeing Io receive the rebate check i <br /> di�ecNy, I ag�ee,to the following: . <br /> 1. The Backwater Prevention Device reba(e amount will be deducled (rom Ihe final invoice <br /> given to the property ovrner for the insfallatlon at the property address referenced above, if ;- <br /> the total cost ofthe installation is prealer,than the re6ate. � <br /> , , 2. I, the Vendor, am a lNashington State licensed contractor. � <br /> � � 3. The Cily of Everett wiil send.a'Federal Fo�m 1099 MISC to me, the Vendor, fo��8ack�vater '` <br /> ' Prevenlion Device rebate payments totaling more than 5600 per ca'endar year, and wi!I � <br /> I , report the same payments to tRe Intemal Revenue Service. ';; � <br /> , � - . . n . .� .� '�` . � . <br /> I accepl the payment of the Back�vater Prevention Devico rebate from the City of Everett pending <br /> 4 approval of the completed Backwater Prevention Device rebate package py the Cily of tve�eft <br /> , <br /> � <br /> °_"��/' � "` � — /U' I � ; <br /> SignaWre of Contractor - — Date — � � <br /> i <br /> � <br /> � <br />