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; <br /> i <br /> , <br /> � <br /> .. . <br /> . : , . ,... . . . . <br /> I <br /> ,. , . <br /> .. <br /> . ; ' { <br /> . I <br /> Contrac'tor Section: ; <br /> ; <br /> ; <br /> , i <br /> .��� ?IU,6�n1�� �1c �r�2'7�` ,V2�'(/ajZ.Z : ��- 7�z- 78� � <br /> Vendor Name/Business N�ame/UBI Number ' ' <br /> , <br /> ( �+.��rP(u /�l- cIIP� <br /> State of Washington Contractor License Number: <br /> 6���// l!/� fzzY2 NLtt.t�. �t'�'"" Z=(i(?lt1�f �C/P�! �f`2-D� l <br /> Vendor Mailing Address ' City State Zip ; <br /> ; <br /> /{ZS�-- ff��i c_ CJIZ� s�t�`}�/v.2r/?�vt-r LC� :��{7�C�r��rr•(.,.L ui:✓� <br /> Phone Email ; <br /> � <br /> I,lhe Vendor, agree lo receive the Backwaler Prevention �evice rebate check direclly for the + <br /> installalion at lhe above referenced property�ddress. By agieeing to receive the rebate check ; <br /> direcUy, I agree lo the Jollowing: � <br /> 1. The Backwater Prevention Device rebale amount will be deducted irom the final invoico <br /> given to the property owner for lhe inslallation at lhe property address referenced abovo, if <br /> the lotal cost of the installalioi is greater than tho rebate. ; <br /> 2. I, the Vendor, am a Washington State licensed contractoc <br /> 3. The Cily of EvereU will send a Federal Form 1099 MISC to me, lhe Vendor, for [3ackwater <br /> Pre��ention Device rebate payments lolaling more ihan $G00 per calendar year, and will <br /> report the same paymenls to the Inlemal Revenue Service. <br /> I accepl the paymenf of the Backwaler Prevention Oevice rehale from the City of[verett pendiny ; <br /> approval of the completed Backwater Prevention Device ret�ale package by the Cily oF Everetl ; <br /> � � <br /> � � <br /> � / �_� � r �/�- , l'�- �- — <br /> v��z� -���%1 Z`;;_ / �"— �..�__ , <br /> Signalurc of Contractor — Date — I ; <br /> � <br /> -- I <br /> � <br /> � <br />