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3 <br /> 1 <br /> F <br /> t <br /> F <br /> 5 <br /> 's <br /> 3 <br /> $Y <br /> Contractor Section: j <br /> tG3- <br /> Vendor Name/Business Nam / UBI Number <br /> State of Washington Contractor License Number: <br /> 17 5 (5 4i'� V <br /> Vendor Mailing Address City State Zip <br /> LQ. -7(vU t� .a��J r--e'l.,� 2 <br /> Phone Email j <br /> I,the Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <br /> installation at the above referenced property address. By agreeing to receive the rebate check <br /> directly, I agree to the following: <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final invoice i <br /> given to the property owner for the installation at the property address referenced above, if <br /> the total cost of the installation is greater than the rebate. <br /> 4 <br /> 2. I,the Vendor, am a Washington State licensed contractor. t: <br /> 3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br /> Prevention Device rebate payments totaling more than$600 per calendar year, and will <br /> report the same payments to the Internal Revenue Service. <br /> r <br /> I accept the payment of the Backwater Prevention Device rebate from the City of Everett pending <br /> approval of the completed Backwater Prevention Device rebate package by the City of Everett <br /> I <br /> i <br /> i <br /> a <br /> Signature of Contractor Date a <br /> F <br /> 3 <br /> 3 <br /> 3 <br /> q� <br /> 3 <br /> 3 <br /> s <br /> j <br /> ;i <br /> S <br /> f <br />