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Contractor Section: <br />Vendor Name / Busine�s Name / UBE Number <br />��-��� �� � �� � � � <br />� <br />State of Washington Contractor License Number: <br />� . � , <br />� i �/� <br />Vendor Mailing Address City State Zip <br />�L.r��-l�� �`3t V..:.-ei' i��i � �s=� �� �l � �� �� �r��Jt�J e Y .�Jd' ! A <br />Phone Email <br />I, the Vendar, agree to receive the Backwafer Prevention Device rebate check directly for the <br />ins#apatian af the abo�e referencec! praperty address. By agreeing to receive the rebate check <br />directiy, ! agree to the following: <br />9. ihe Backwater Prevention Device rebate amount wiil be deducted from the finaf invoice <br />given to the properEy awner for the instaElatian at the property address referenced above, if <br />the total cast of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. 7he City of Evereit will sencf a Federal Form 1099 MISC fo me, the Vendor, for Backwater <br />Prevention Device rebate payments to#aling more than $600 per ca{endar year, and wi[i <br />report the same payments to the Internal Revenue Service. <br />1 accept the payment of the Backwater Prevention Device rebate from the City of Everett pending <br />approval af #he completed 8ackwater Preven#ion Device rebate package by the City of Evere#t <br />� <br />Signature of Contractor <br />Date <br />