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C�ntractor Section: <br />Vendor Name / Busine�s Name ! UBI Number <br />�������� ���� <br />State �f Washington Contractor License Number: <br />.��1 � �...�a;,� � i ��, � � � ��.�,� .`t-I�" _�� �' �:��%=� <br />Vendar Mai[ing Address City State Z[p <br />��j�;���'� "�� �� �i�''1C�c � � f �_ �' <br />t �-_-�� c�� ��� ���¢ r3l�i d"'_t_`� <br />Phone �mail <br />!, the Vendor, agree to recei�e the Backwater Preventian Device rebate check cfirectiy �or tf�e <br />insfallation at the above referenced praperty address_ By agreeing to receive the reba#e checic <br />directly, I agree to the folfowing: <br />1. The Backwater Prevention Device rebate amount wil[ be deducted from the final invoice <br />given to the property owner for the installation at the property address referenced above, if <br />the total cast of the instafiation is greater than the rebate_ <br />2. I, the Vendor, am a Washingtan State iicensed contractor_ <br />3. The City of EveretE will send a Federal Form 1099 MISC to me, the Vendar, far Backwater <br />Prevention Device rebate payments tota[ing rr�ore than $600 per cafendar year, and will <br />repor� the same payments #o the internal Revenue Service. <br />I accept the payment of the Backwater Preven#ion Device reba#e from the Cify of EveretE pending <br />apprava! af the completed BacKwater Prevention Device rebate package by the City of Everett <br />Signature of Contractor <br />Date <br />