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Contractor Section: <br />Vendor Name 18usine�s Name / UBI Number <br />�- - -�--�Tf���-i-�--- <br />Slate of Washington Contractor License Num6er. <br />Vendor Ulailing Address <br />Phone <br />�iry State Z�P <br />C�c:�.�• c.� ' r�Cli� � � r-��'iJ_— <br />Email <br />I, the Vendor, agree lo receive Ihe �ackwater Prevention Device rebate check directly (or t'ne <br />inslallation at the above referenced properiy address. By agreeing to receive the rebate check <br />directly, I agree to the following <br />1. The BackLvater Prevention Device rebate amount v�ilPb Pdeducted from the final invoice <br />given lo ihe property o�vner for Ihc installation at Ihe ro e �ddress re(erenced above, if <br />the totai cost of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washin�ton State licensed coMraclnr. <br />3 The City of Everett r�ill send a Foderal Form 109d MISC lu me, 1he Vendor, for Rackwater <br />prevention Device rebato paymenls tolaling more lhan 5600 per calendar year, and will <br />repurt the same paymenis to Ihe intemal Revenue Service. <br />� <br />I accept lhe p�yment oi the Back�vater P�evention Device rebate irom lhe City of Everett pending <br />approval of the compieted Beck�vater P�evenlion Device rebate package by Ihe City of Everett <br />� <br />�__�-1��_— <br />Signature o( Contractoi <br />M <br />-��C1- I1 � _, <br />! <br />Date <br />