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-� <br /> Contractor Section: <br /> � , � M�l��t-r� r� ���z�����1�r� r�--�a_- ��� <br /> Vendor Name I Business Name f UBI Number� <br /> � pl�l�airPQ - --- <br /> Slate o(Washington Conlractor License Number: <br /> �� � vc�/s�t__6`i'�= -��ziw�T w�- 9�2� 3 <br /> Vendor Mailing Address City State Zip <br /> �I Zs�1�j1 f— Q�I Z � ����I'N �/Yl.�Ll(�0"7l_�C,�/Ytac.� • L Ul'+'� <br /> Phone Email <br /> I, the Vendor, agree to receive the 8ackwater Prevention Device rebate check directly for the <br /> installation at the above referenced property address. By agreeing lo receive the rebate check <br /> directly, I agree to the following: � <br /> 1 The Backwater Prevenlion Device rebate amo�mt�vill be deducted from lhe tinal invoice <br /> given to iheproperty owner for the installalion al the property address referenced ahove, d <br /> ihe tolal cost of the installation is greater than thc rebale. <br /> 2. i, the Vendor, am a Washingion State hcensed contraclor. <br /> 3. The City of Everelt will send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br /> Prevenlion.Device rebatepaymenls totaling more lhan $600 per calendar year, and �vill <br /> report t�ie same payments to Ihe Inlernal Revenue Service. <br /> I accept the payment of the 8ack�vater Prevention Device rebate from the City of Everett pending <br /> approval of the completed Backwater Prevention Device rebate package by the City o(Everetl <br /> _ <br /> � � <br /> .� ���-/5� <br /> Signature of Contractor Dale <br />