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� <br />Contractor Section: <br />� D�'_��1 �� � LtM h��� <br />Vendor Name / Business Name <br />LL� <br />UBI Number <br />r i�) C'_�` Pp �� g?s 5) � <br />State of Washington Contractor License Number: <br />f 75 IS �f i`� S6 `. <br />Vendor Maili�ig Address <br />y�1`- '76u <br />Phonc <br />3 - �!(�3- ��`r <br />Sn����,�r��. �✓k1 �b-2`i(� <br />City Siate Zip <br />i ��,n3� C-�. Mo�n l��ti,...h;,zy.�_�:� <br />[mail <br />I, the Vendor, agree to receive ihe Backwater prevention Device rebate check directty for the <br />inslallation at lhc a6ove referenced property address. By agreeing to receive the rebate check <br />direcQy, I agree to Uie folloering: <br />1 <br />2. <br />3. <br />The Back�vater Prevenlion Device rebate amounl will be deducted from the final invoice <br />given lo the properly o�vner for lhe inslallation at the property address referenced above, if <br />!he lotal cosl of the instailation is greater than the rebate. <br />I, the Vendor, am a Washington State licensed contractor. <br />TLe Ciry of Everett will send a �edcrel Form 1099 NISC lo me, lhe Vendor, for Dackwa,er <br />Prevention Device rebate paymen(s totaling more than $600 per calendar year, and will <br />report the same payments ;o the In;ernal Revenue Service. <br />I accept the payment of the Bacfnvater Prevention Device rebate irom lhe City of Fverett perding <br />approva! of tne completed Backwaler Prevenlion Device rebate packac�e by the City o( Everett <br />lti,.Ql �.�--- 1 c� - ly-ilf <br />Siynature of Contractor Date <br />