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Contractor Section: <br /> /7�!1 L14G�1.�.��7 L NCr �`YJ} ...U� � .' �s� <br /> Vendor Name!Business Name/ UBI Number <br /> /_�r�l �'i ���� _ <br /> 5tate oi Washington Contractor License Number: <br /> S��/c�7 '7/'r/}v� N,L M/�1ZYSVL/L; lN/1 y',��;�.� <br /> Vendor Mailin�Address City Slaie Zip <br /> �%'_���7��a 7 <br /> Phone ` Email <br /> I, the Vendor, agree to receive lhe Backrrater Prevention Devic= rebate check directly for the <br /> install�tion at ihe ahovo re(erenced properiy address. By agreeing to receive the robate check <br /> directly, 1 agree to the follo�ving: <br /> 1. 7i��, BacRc�ater Prevention Device rebate amount�vill be deducted trom the final invoic� <br /> yiven !o the property owner for the instaliation at the properly address referenced abov2, i� <br /> the total cost of the Installation is gr2ater than the rebate. <br /> 2. I,the Vendor, am a Washington State licensed contractor. <br /> 3. i'he City of Everett will send a Federal Form 1099 MISC to me, tho Vendor, for B�ckvlater <br /> Prevention Device re'�ale payments totaling more than $u00 per calendar year, and ��✓ill <br /> report lhe same pap .�ents lo the Inlernal Revenue Service. <br /> --- -- --- � <br /> I ac.cept the payment of lhe Dack:vater Prevention Device rebate trom Ihe Gty of Everelt pendiny � <br /> appraval of the compleled f3ackwater Prr.vention Device rebate padcage by lhe City of Everelt <br /> / <br /> I, �- � - l5 _ <br /> Signature of Contraclor __ Date <br /> �_____ ___ __ . _ _ __ ____ _____ <br />