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Contractor Section: <br />, <br />/�I;�.1,,'.O 1�..n�i;L�/G ��.2�-�l � -�iSS� <br />Ve�, '�r Name / Business Name / UBI Number <br />�% �L4 �' � GT - <br />Staie oi Washinglon Contractor License Number: <br />.�`/r%7 7/S rf}V� "�i= /1��i)i�.s ili�j� 1//i �� G <br />Vendor Mailing Address City State Zip <br />(�� � .S���J-'�.�G7 <br />Phone ' Email <br />I, the Vendor, agree to recelve the Backwater Prevention Device rebato check directly for lhe <br />installaiion at thr, above reterenced propert�� adtiress. By agre�ing to rec2ive lhe rehate check <br />direclly, I agree to the follue�ing: <br />1. TP�e Backtivater Prevention Device rebate amount will be deducted from the final involce <br />givan lo the property o�vner for the installation at lhe property address referenced above, if <br />the fotal cosl of Ihe inslallaUon is gre�' :r lhan the rebate. <br />2. I, the Vendcr, am a Washington State lir,ensad contrac;oi. <br />., The City of Fverett ivlll send a Federal Form 1099 MISC to me, th� Vandoi,',cr B.�dava(ei <br />Prcvenlion Devir,n rebale payments totaling more than 5600 �;er cal�ndar year, and �rli <br />report the same payments to the Internal Revenue Service. <br />I ascept Ihe payment of !he �ackwater Provention Cevlce rebate from fhe Cily of Everell pendin� <br />approval of the completed f3ack�valer Prevenlien Device rebate package by the Cily of Everelt <br />l <br />�1- �- IS <br />Signature of Contractor �—__. Date <br />