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i <br /> � ; <br /> � <br /> � � <br /> , <br /> ; <br /> ; <br /> , <br /> Cooitractur Sectlon: � <br /> �`�l,`c'� ���tnrti ���1 ' (: L� �. �isj�1 <<-( � <br /> . <br /> Vendor�lame/Business Na e!UBI Number i <br /> M ��.n PP� �-u � .i�, � <br /> State of Washington Contractor License Number: <br /> i-�S i s _�r� ,,- �f. Sr 5,����r-„ s�, w/4 �,�7_�j o <br /> Vendor Mailing Address City State Zip � <br /> �l �. S• 7(; O 5���-G' ? frnf�J i�� uC=et ,���,-,l�ir� . co�h <br /> Phone Emall <br /> i <br /> I, the Vendor, agree to recelve the Backwater Prevention Device rebate check directly for the <br /> installation at the above roferen�ed �roperry address:By agreeing to receive the rebate check <br /> dlrectiy, I agree lo the following: <br /> 1. The 8ackwater Prevention Device rebate amount wlll be deducted from the flnal invol�e <br /> given to ihe property owner for ihe installation at the property address referenced ahove, if <br /> the total cost of the installation is greater than the rebate. <br /> 2. I,the Vendor,am a Washington State licensed wntractor. <br /> 3. The City of Everett will send a federal Form 1099 MISC to me, the Vendor,for Backwater <br /> Prevention Device rebate payments totaling more than $600 per calendar year, and will <br /> report the same paymenls to the Internal Revenue Service. <br /> ; <br /> I ac�;ept the payment of lhe Backwater Prevention Device rebate irom Ihe City of EvereU pending <br /> opprovel of lho comploted Backwater Preventian C:vice rebate packago by the City of Everett <br /> � 2(�✓� ���77i�'�—. � �� � ��� � <br /> Slgnature of Contractor Date <br /> � <br /> i <br /> � <br />