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Contractor Section: <br />l� ��� i� i �;� � , �. � � �. � --- � �.� - �-r � 3 �- � C� �� <br />Vendar Name / Business Name� UBE Number <br />�i (,� c'_�` {� �' '�` �� � ,) � <br />S#ate of Washington Contractar License Nurrtber: � <br />i % :� { � �� j s� S� �,� �f'i �i �I �J s�, � i � i_.�,�' crl �`-'� U <br />Vendor Mailing Address City State Zip <br />`� �.J`f ��oU ` '� � <br />� �� t �'.�lz��'" �. �'i-'l c� �'1�,��J ���� _�� ��-, <br />Phone <br />�maiI <br />I, ihe Vendo�, agree to receive the Backwater Preventian Devlce rebate check directly far the <br />installatlon at the above reterenced properfy address. By agreeing to receive the rebate check <br />direct[y, ! agree to the foliawing: <br />1. The Bacicwater Prevention De�ice rebate amount wiif be deducted from the final invaice <br />given to the property owner for the installation at the property address referenced abave, if <br />the total cost of the installation is greater than the rebate. <br />2. I, the Vendor, arn a Washington Sia�e licensed contractor. <br />3. The City af Everett will send a Federa) Form 1099 MISC to me, the Vendor, for Backwater <br />Prevention Device rebate payments totaling more than $600 per calendar year, and wi(I <br />repart the same payments to the Enternal Revenue Service. <br />I accept the payment of the 8ackwater Preven#ion Device rebate from the City of Everett pending <br />8ppfoval of the completed BacEcwater Prevenfion �evice retaate package by the City of Evereti <br />5ignature af Contractar <br />2- �`-lr�� <br />Date <br />