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� cra�traeCop ��c�io�i: <br />�'�Cc'_./� I�I1nr�.l7�tlr',�_ __.._ _ U�.�� iJ��'! � <br />Vendor Name I Business Nar1% I UBI Number <br />Nl oer� PI':� Y�,- � J 1 � <br />Slale of Wachington Contractor License Number: <br />I 7 S � S �r I`—'� Sf_S E Sno�� or`-�� Sl-. i.✓ j1 �, �7_°) U <br />Vendor Mailing Address City State Zip <br />�i � S %�� U�f��,Ci I fr nT �J it� C)C�n f7�t�,ti%!��y'. co��i <br />_ 7 <br />Phone Emeil <br />I, the Vendor, agree to recelve the Backwater Preventlon Device rebate check dlrnctly ior the <br />Installation at the ahove referenced property address. By agreeing Yo recelve the rebate cheGe <br />directly, I agree to lhe following: <br />1 <br />2. <br />�� <br />Th2 Backwaler Prevention Device rebate amount wili be deductetl from the finai invofce <br />�iven to the property oivner (or the installalion at the propetty address referenced above, ii <br />the lolal cosl oi the inslallation is greater than the rebato. <br />I, the Vendor, am a Washlnpton Slate D,:ensed canlraclor. <br />The Clty of Everettwill send a Federal Form 1099 MISC to me, the Vendor, for Backvdater <br />Prevenlion Device rebate paV�nents totaling more than 5�GG0 per r.alendar year, and wiil <br />report the same paymenls to ttie Inlemal Revenue Servlce. <br />I accept the paymenf of Ihe �ack:�ater Prevenlion Device rebate trom the City of Everetl pending <br />apprnv�l of �he completed f3ackwatrr Prnventlon Dnvicr. rubnle par,kaqe by Iho City of Evcrett <br />�,�V,✓1 V��177i1i"'�" <br />SlgnaWro of Contractor <br />S-� �'"1� <br />Dale <br />