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j <br /> � <br /> E <br /> -� Contractor Section: . <br /> r,— ' , — --—J--` ,.c�.'!� LLG (��� ,_�� ' �3�5 <br /> ��'ics�.� �c. l 5 -�--•� i--- � ��_ I <br /> Vendor Namo I Eiusine s Name/UBI Number <br /> ,9.`L'I��.I �--�-��—�-�- -- - <br /> State of Washington Cuntractor License Number: <br /> a�,��o�tl:l'�i�'1�-P,�—�L✓�L�:�".1,�c-__�'��G.� � <br /> Vendor Mailing Address Ciry S1ate ZiP � <br /> a��i�:�s� L��r,c��t r is:�a��l <<i��cD��7 <br /> Phone Email � <br /> �_� <br /> I,the Vendor, agree to receive lhe �ackwaler Prevention Device rebale check direclly for Ihe <br /> installation at the above referenced properfy address. Qy agreeing lo receive the re6ate check <br /> directiy, I agree to the tollovnng� <br /> 1. The Backerater Prevenlion Device rebate amount will be deducteo irom the final invoice <br /> given lo lhc property o�vner for the installation et the prope�ty address referenced above, if <br /> the to[al cost of the instal!ation is greater than the rebate. <br /> 2. I, Ihe Vendor, am a Washinglon State licensed contractor. <br /> 3. Thc�City oT Everett will send a Federal Form 1099 ti11SC to me,lhe Vendor, tor Backwaler <br /> Prevention Device rebate payments totaling more than $n00 per calendar year, and e�iil <br /> report the samc peyments to thc Inlcrnal Revenue Service. <br /> 1 accept tlie payment of the Backwater Prevention Device rebate trom the City oi Everett pending <br /> approval of the completed Backwaler Prevention Device iebale packac�e by the City oi Fverett <br /> �� ..�'���-N-G-'� ' - ' <br /> _—l��d------ <br /> Signature of Contractor Date <br />� ' <br /> ' <br /> � <br /> • , <br /> ys , <br />