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. � <br /> I <br /> i. <br /> � <br /> � <br /> 1 <br /> Contractor section: . � <br /> I <br /> /� �',. i <br /> WU_C4�����j��, ��������—,9�ic�c.'C� LLc. /:c�', ; � �.3 �' ! <br /> Vendor Name/BusineSs Name/UBI Number ; <br /> � <br /> � � <br /> �1N�_�-F��`�-� -K-�- ; <br /> Sla[e of Washinc�ton Contractor License Number. i <br /> �lb�P.t� L�,r_lia—L�-(_',,--�W�rr�:i� ���1'�5��� ; <br /> Vendor Maili�g Address City Stale Zp � <br /> a�,�1_n. � c�g�_C'�nd�Gzc:c_�,��.��l�nt��:�t�"Z � <br /> Phone Email � <br /> r <br /> i <br /> , <br /> I, ihe Vendor, a�ree lo receive lhe Dackwater Prevention Device rebate check directly for lhe � <br /> inslallalion at the a6ove referenced property address. By ayreoing to receive the rebale check <br /> directly, I agree to the following: � <br /> � <br /> 1. The Backwaler Preve�tion Device rebate amount will be deducted from lhe linal invoice � <br /> given fo lhe property owner ior the inslaitation at lhe property address referenced above, if � <br /> lhe lotal cost of the mslallatinn is greater lhan Ihe rebale. ' <br /> i <br /> 2. I, the Vendor, am a Washington Stale licensed contraclor. j <br /> 3. Tho City of[verell will send a Federal Form 1099 MISC lo me, �he Vendor, for Backwaler f <br /> Prevention Dovice rob�te paymenls totaiing more than $G00 per calendar year,and will i <br /> report Ihe same payments to Ihe Inlernal Revenue Service. ; <br /> -- — i <br /> ---- � <br /> I acr,ept the paymenl of the Backveater Prevention Uevico rebate(rom tlie Ciry oF Fverett pending ; <br /> ❑uP�oval ot the compleled Backwater prevention Device rebate package by the City of Fverett � <br /> i <br /> � <br /> �/ ��I/ l— i <br /> �L-.��f� �111--- I <br /> Signature of Contraclor Date <br /> i <br /> � <br /> — --- � <br /> I <br /> � <br /> � <br /> i <br /> � <br />