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Contractor Sec�ion: <br />i� � <br />(' ' 6� � � L- G (� l�'� _ �( l�J � '- l% [r7 � i <br />Vendor Name ! Business Nam <br />tJBi Number <br />� LJ C'� {� I� �'` i�� � .) � <br />Stafie of Washington Contractar License Number: <br />��� � i S y' i s� jd � �r�, ��� a� t�r� Ly�- �i�.�� � <br />Vendor Mailing Address City State Zip <br />�"% p� �� �� � tJ •, �,1� J � '''�/"t� C:-� �'L'% (:+C'.�'1 ,'z.ZN►%�1 �f' L , E�:: i'~� <br />Phone Emaii <br />f, the Vendor, agree to receive ihe Backwater Prevention Device rebate check directly for fhe <br />installation at the abave referenced property address. By �greeing to receive the rebate check <br />directly, 1 agrae fo the followfng: <br />'i . The Backwater Preven#ion Device rebate amount wiil be deducted from the fiinal invoice <br />given to the property owner for the instaiiation at the pro�erty address referenced above, if <br />the totai cost of the installetion is greater than the rebate. <br />2. l, the Vendor, am a Washington Siate licensed contractor. <br />3. The City of �verett wil[ send a Federal Form 1099 MISC to me, the Vendar, for Backwater <br />Prevention Device rebafe payments toiaiing more fhan $60Q per calendar year, and wifl <br />repart the same payments to the lnternal Revenue Service. <br />� accept the payment of the Backwater Prevention Device rebate from the City of Everett pending <br />�pprovai of fhe completed Backwafer Prevention Device rebate pacicage by the City of �verett <br />�z� �/�'�-� <br />Signature of Can#ractor <br />f--f — 7— I � <br />Date <br />