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I <br /> � <br /> � <br /> � <br /> ( <br /> ; <br /> I <br /> Contractor Section: 4 <br /> l � <br /> r I , <br /> i <br /> � , - - , n �. �` �it%{�l_LC. r�r;-'` ,-32.-`ty?.3$ + <br /> � <br /> Vendor Name ! Busine s Name I UBI Number � <br /> r ! <br /> �/ :._r"�E.�'�Lr�_�—�`- .iv�—�-�- <br /> Stale of�Washington GonUacror License Number. i <br /> � <br /> i �� �-� ' j�1-fll',.-�_�I.�:r�1'f'�t`�� r�'�� ; <br /> I Vendor Mailing kddress City Scate Zip ' <br /> �._Ln,�n4� �'�� r i ���_ a�.a ���rx�, ����2_ � <br /> Phone Email ; <br /> { <br /> I <br /> I, the Vendor, agree to receive lhe E3ackwater Prevention Device rebate che�k direcUy for the ', <br /> installa!ior, at the above referenced �roperty address. By agreeing to receive ihe rebate check � <br /> direcJy, I agree to the following + <br /> i <br /> 1. 7he 6ackwater Prevention Device ret�ate amount will be deducted from th� final invoice <br /> i <br /> given to the property owner for the �nstallation at the property address referenced above, if <br /> the total cost of the instailation is greater than the rehate. ! <br /> 2. I, the Vendor, am a VJashington Sta'e licensed contractor. � <br /> 3. The City of[verett will send a Federal Form 1099 MISC to me, the Vendor, for Backwater i <br /> Prevention Device rebate payments toialing more than $600 per calendar year, and tvill <br /> report Ihe same payments to lhe Internal Revenue Service. <br /> -------'-- — . i <br /> I accepl lhe p�ymenl uf the Back�valcr Prevention Device rebate from the City of[verett pending i <br /> apUroval of the completed Backwater Prevenlion Device rebate package by the �ity o(Everett <br /> I <br /> � <br /> 1 ��� � <br /> � �5 5 (� � <br /> C���.�!'. ' ����-= - - � � i <br /> Signature of Contractor Date <br /> L ---- --- - — — ; <br /> i <br /> i <br /> i <br /> I <br /> I <br /> i <br /> I <br />