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Contractor Section: <br />_I'1 �� ,� P1�.�,ti,;^ <br />Vendor Name l Business Name, <br />Number <br />N�ven ��P �►` �S� 3.j p <br />S!ate o° Waslfngton Contractor License Number: <br />+�5�5 �iis� sf <br />Vendor ��lailing Address <br />��zs ��v s� <br />Phone <br />S��o �, cr� � �i � <br />City <br />�f rc� J � �yo c/� <br />Email <br />w1� ���c� <br />Sla[e Zip <br />I, lhe Ve��dor, agree to receive Ihe Backr�ater Prevention Device rebata check di�ocily for the <br />installetioa at lhe above re(erenced property address. By agreeing to roceiva the rebate check <br />directly, ' a9ree to (he (ollov✓ing: <br />1. The Backwatar Prevention Device rebale amount will Ue detlucieC irom the final invoice <br />g�ven to the property o�vner for thc instellation et the property addreso reterenced above, if <br />Ihe total cost of lhe installation Is groa�er than the rebate. <br />2. I, the Vendor, am a 1Nashinglon State licensed contraclor. <br />3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for Backeva�er <br />Prevention Device rebate paymenls lotaling more lhan 5600 per calendar year, and will <br />report lhe same payments to the Intemai Revenue Service. <br />I accept the payment of the f�ackwater Prevention Dewce re6alo from the Cily of Everett pending <br />❑pproval ot the compieted Rack�valer Prc+vention flevice reCa1e par,ka�e by th� City of Everctl <br />/ f �y � <br />•Z�� 1 0 , ��'"�-'-�-'�--- <br />Slgnature of Contractor <br />�( ;��(—l� <br />Date <br />� <br />