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Contractor Section: <br />Vendor Name ! Busine�s Name 1 UBI Number <br />A IvI �� � �__�-- �� � � - <br />State of Washington Contractor License Number: <br />Vendor Mailing Address <br />�'_Yp/ 7�4 <br />Phone <br />� � �„ ��� <br />City <br />�;�ti�'�d i` � ' i <br />Email <br />State Z�p <br />I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <br />instaliation at ihe above reFerenced property address. By agreeing ta receive the rebate check <br />directly, I agree to Ehe foilowing: <br />2. <br />3. <br />The Backwater Prevention Device rebate amount wiif be deducted from fhe final invoice <br />given to the property owner for the installation at the property address referenced above, if <br />the total cast of the instaliation is greater than the reba#e_ <br />f, the Vendor, am a Washington State licensed contractor. <br />The City of Everett wiil send a Fecieral Form 1099 MISC to me, the Vendor, far Backwater <br />Prevention Device reba#e payments totaling more than $600 per cafendar year, and will <br />report the same payments to the lnternal Revenue Service_ <br />[ accept the payment of the Backwater P�evention �evice rebate from the City of �verett pending <br />approvaf �f the completed Backwater Prevention Device rebate package by the City of Evere�t <br />� <br />.�_r,� .,.�.. ' <br />Signature of Contracfiar <br />� � <br />D aCe <br />