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i <br /> ; <br /> i <br /> � � <br /> i <br /> I <br /> Contractor Sectinn: i <br /> I <br /> i _� — i <br /> , � <br /> i�l'�i%,�.�,M� �n/rr ��.>' — G% � — G S� � <br /> Vendor Name / Business ��ame/ UBI Numbar � <br /> I ___/"11L4 f'� ..,,� .L'� � <br /> State of VVashington Contraclor L'+cense Number: � <br /> � -`�`�Z__Z 5�✓� /V�-- /1'�/�IZYSVilvL� iN/i ��?,'o _ <br /> � Vendor Mailing Address City Slate Zip � <br /> � ��L�_�_i��7 ` <br /> IPhone ` Email + <br /> I � <br /> � <br /> I <br /> I, tne Vendor, agree to receive ti��a Back�:rater Pre�dention Devi�� rebat=cneck direc�ly for iha � <br /> installalion at ihe abov2 rerererced property address. By agreeing co receive the rebate check � <br /> ciirectly, I aaree to ihe folio�ving: <br /> i <br /> 1. Th3 BacK+•+zter Preven(ion Device rebate amount�vill be deductad `rom the fin21 invoice <br /> given to ihe property oivner for the installation at the oroperty address referenced aoove, ii ' <br /> ?he total cost of the ins(allation is greater than the rebato. <br /> 2. I, 'he Vender, am a Washington Staie lic2nsed centractoc <br /> 3, Tha City of Evereh v�ill send a Federal Form 1099 MISC to me, tt�e Vendor, for Backwater i <br /> Prevention Devio� rPbale poymenis iotalir,a more than 5600 per calendar yaar, and lvill � <br /> report lhe same payme�ts to the Internal Revenue Servi�e. � <br /> �------ — ` <br /> I I 2cc2p;the payment of the Ba�kwaler Prevention Device rebate from the City of Everett pending <br /> approval of the compteted BackwatEr Preveniion Device rebata package by the Ciiy of Everett � <br /> I <br /> I <br /> i <br /> ; <br /> � , <br /> . _. s=a�.�-� � <br /> Signature of Contraclor __, Date ! <br /> — � <br /> I <br /> � <br /> � <br /> � <br />