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Contrac#or Section: <br />Vendor Name / Susi <br />� <br />Name / UBI Number <br />�r s � � <br />I� _ _�i � e� � (r� <br />State of UVashingtan Contractor L.icense Number: <br />Vendor Mailing Address <br />Phone <br />City <br />`6 � !'-F7 ,� �, <br />t� i�,l-(_ _r�� <br />Email <br />._'� � �C�+�� <br />State Zip <br />I, the Vendor, agree ta receive the Backwater Prevention Device rebate check directly for the <br />instaliation at the above referenced property address. By agreeing to receive the rebate check <br />directly, t agree ta the foliowing: <br />1 <br />Pa <br />3 <br />T�e gackwater Prevenfion Device rebate amount wil! be deducted from the final invoice <br />given to the property owner for the instailation at the property address referenced above, if <br />the total cost nf the installation is greater than ihe rebate_ <br />I, the Vendor, arri a Washington State licensed contractor. <br />The Ciiy of Everett will send a Federai Form 1 D99 MiSC to me, the Vendor, far Backwater <br />Prevention Device rebaie payments totaling more fhan $600 per calendar year, and will <br />report the same payments to fhe 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 />� <br />Signa#ure of Contractor <br />-- (J�"-(,�� -- <br />Date <br />