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Contractor Section: <br /> ----- -- _ . . ---- <br /> CU�JJv` " � �-�-� �v02- ��?- �13 <br /> "�f��V��i- - 1� ��um � ► � - -- -- � <br /> Vendor Name I Business Name/ UBI Nurnber \, I <br /> --�1 �f�'0//Ol-� _ _- -- -- I <br /> Slate ot Washingtun Contrador License Numbe <br /> - ���I_�_/if�r��s�j� l�� _��,1r �- �� � b I <br /> VenAor Mailing Address City State Zip I <br /> I <br /> L-�2_� �� S- �Iz>- -�I j'�/�•����c�� C(_�.�����r�{II.cH� <br /> � Phone Email I <br /> I — — _ -- --- -_ _ _ .. � <br /> I,the Vendor, apree lo receive Ihe Backwaler Prevention Devir.n rr.balr chr.ck direclly for the <br /> installahon al the above relerenced property address. By agree�ng lo rocerve Ihe rebate check <br /> direclly, I agree to the lullnwing <br /> The Backwaler Prevenlion Device rebntc amounl wdl be deducted!rom Ihe final invoice <br /> given�o Ihe propeAy owner for!he installa6on at the property addn�ss reterenced above, d <br /> Qie total cosl o(tl�e installal�on is greater Ihan the rebate <br /> 2 I, U�e Vendor, �m a Washmgton State brensed conhactor <br /> 3 The Cily of Everett will sen0 a Federal fo�m 1099 MISC to me, ihe Vendor, lor Baclavater <br /> Prevenlion Device rebate paymeMs totalmG morn than$C,00 per caicndar year, nnd w�ll <br /> rr.port the samc payme.nts to Ihe Internal Ftevenue Service <br /> �I accept Ilte pnymenl of ihe Bachvvaler Prevenlion Device rebat�� Irom tlu�Cdy ut Evercl� p��ndin�� I <br /> approval of the completeA [Sackwater Preventron Dewcr� r�tia�e package by the Cdy ol [verMt <br /> i <br /> � ` � I <br /> � 1�� � � Zo�s <br /> - -�J� - <br /> ISign� 1 CoMractor __ . --- .. _ .. —— D��c I <br /> � � <br /> I <br />