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Contra�tor ��ction. <br />�' 'a , �: t� � iv'.�-� ���.� �. � ;�,.�- <br />Vendor Name / Business Name / UBI Number <br />� <br />State of Washington Gontractor License Number. <br />�'''f"'`�.� <br />���� �1 j���iW� _ ��r1�'� ��'���� <br />V�ndor Mailing /�►ddress City Stat� Zip <br />�»'��� --� �'� � �- � � `°� :-� � ��� �f � � � ���- ���,.z <br />Phone Email <br />I, the Vendoe, a�ree to receive #he �ackwater Prevention �evice rehate check directly far #he <br />ins#allatiQrt �t the abave ref�renced prr�perty acidres�_ By agre�ing to rec�iv� the rebafie check <br />directly, I agre� tQ the following_ <br />1. The Backwater Preven#ion Devicg �ebafe amount will be deduc#ed from the final invoice <br />given to the property awner for the instaUation at the property address referenced above, if <br />the total cost of the installation is greater #han the rebate. <br />2. !, the Ventlor, am a Washington State licenssd contractar. <br />3. The City of Euerett wifl send a Federal Form 1fl99 MISC to me, the Vendor, for Backwater <br />Preventian Device r�bate payments tota�ing more than $60p per calendar year, and will <br />report the �ame payments to the Internal Revenue Service. <br />I accept th� payment of the Backwater Prevention Device rebate from the Ci#y of Everett pending <br />approval caf the eompleted Ba�kwater Preventian �evice rebate package by the City of Ev�rett <br />�. <br />� <br />Signature of Contractor <br />�-�6�, � �--- `� �� � � �� <br />a��� <br />� <br />