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Contractor Section: <br /> � -—- ---- ---- --------- � <br /> �' /����rq_�/u��-.y - - (�oj o%3 u.Ss! <br /> I Vendor Name/ Business Name/ UBI Number <br /> . <br /> II �4ro//�L_�o�Gr -- ---- — - — I <br /> Slate of Washington Coniraclor License Number: <br /> S��G7 J�f� JI✓Pi NC_ _/�'7G/YSVf//G WA' y�'JZ7CJ _ <br /> Vendor Mailing Address Gity Slate Zip I <br /> I �s7 387- �.So> - — -- <br /> Phone Email <br /> I <br /> I, the Vendor, a�ree to receive the Back•xater Preventlon Devlce rebate check directly lor the <br /> installation at lhe above referenced property address �y agreeing lo receive the rebate check <br /> directly ' agree lo the followmg. <br /> 1 The Backwater PrevenUon Device rebale amount rrill be deducted from the (inal invoice <br /> given to the property oarner for the installaUon at !he property address referenced above, rf <br /> Uie lotal cost of ihe inslallaUon is greater ihan the rebale. <br /> 2 I, Ihe Vendor, am a Washington Slate hcensed conlraclor. <br /> 3 The City of Everell viill send a Federal Form 1099 MISC to me, lhe Vendor, for Backwater <br /> Prevention Device rebate payments tolaling more ihan 5600 per calendar year, and �•:dl <br /> report the same payments to the Internal Revenue Service <br /> � I accep� the paymen� of�he Backtvaler Prevention Device rebafe Gom Ihe Crty ol EvereU pending <br /> approval of Qie con�c�eled Eiackwater Prevenlion Device rebale package by the City o(Everelt <br /> � — —" //9�/S" � <br /> Signalure of Contraclor Date <br /> i <br />