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- <br /> Contractor Section: <br /> j � o�n I� I - � i <br /> �,� h � �� � � C C-�b3 I �3 - �� � � <br /> � Vendor Name/Business Name�/�umber I <br /> i M v c�r� P P-t` SSSS s� J I <br /> State of NJashington Contractor�icense Number. <br /> I 7S IS �tl`d� Sd 5(�' Sn�i�v�,��c�. wkl �rb2`iu <br /> ' - - —.— <br /> Vendor Mailing Address Cib� State Zip <br /> �i��s 7c�u �s3�c; r��,,,b �-� n-�o�,n��u,.,.h;,, .��;�. <br /> Phone Email <br /> � <br /> I, lhe Vendor, agree to receive the �ackwafer Prevention Devlce rebate chec:t dire�tly fer the <br /> installation at the above re(erer.ced property address. By agreeing to receive the reba,e check <br /> di;ect!y, I agree to the fallowiny. <br /> 1. Tne Backwater Prevention Device rebale amount vlill be deducted irom �he final irvoice <br /> given to lhe property ov✓ner tor the installa!ion at the property address re'ererced arove, if <br /> the,otal cost of the installa!ion is greater lhan the rebate. <br /> 2 I, the Vendor, am a �A�ashington State licensed contractor. <br /> 3. The City of Everett will send a Federal Porm 1099 MISC Io me, tne Vendor, ior Eack�vatzr <br /> Prevention Device rebate payments tntaling more than 5600 per calerdar yea�, and v�ill <br /> report the same payments :o the Intemal Revenue Service. <br /> I accept the payment of lhe �acfovaler Preventinn Device rebate (rom the City of Fverett pending <br /> approval of the complefed Backwater Prevention Devic� rebate packac�e by lhe City of EvereU <br /> I <br /> � "�-J�-7��l- - -- L�"=�i- i f — <br /> I Signature of Con:raclor Date <br /> I�_ — _ — -- — _ -- — — - ----- - <br />