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i <br /> 3 <br /> I <br /> 't <br /> 3 <br /> 3 <br /> Z <br /> Contractor Section: <br /> i <br /> Mocin P ! L1&4 L &C L <br /> Vendor Name/Business Nam7/ U131 Number <br /> State of Washington Contractor License Number: <br /> s <br /> Y <br /> � �� / �q� �j 3 <br /> f 7 �I 11s� �C� 31 �r�i a lr!L�S Yt 1 C"! {_, P ci Q zi--.q f <br /> Vendor Mailing Address City State Zip <br /> r <br /> 7C c) <br /> �U ice" C`... et4"'f'n ��,v►�j ick C G -� y <br /> Phone Email <br /> } <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, l agree to the following: <br /> 1. The Backwater Prevention Device rebate amount will 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 cost of the installation is greater than the rebate. r <br /> 2. I, the Vendor, am a Washington State licensed contractor. <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 /> 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 /> ' E <br /> 3 <br /> 2 <br /> Signature of Contractor Date <br /> z <br /> a <br /> 's <br /> d <br /> 4 <br />