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i <br /> i <br /> � <br /> i <br /> Contractor Section: i <br /> I ; <br /> �iu1�[�c��r�,s✓� ��3 —c�13 - ussr j <br /> Vendor Name/ Business Name! UBI Number ; <br /> �r�Ll ' c:'_�i � <br /> State of bLashingron Contractor License Numbsr: , <br /> i <br /> s��� �� �v�, _ M��zys�Lr�,: w� ���;� <br /> IV�r,dor Mailing Address Ciry State Zip ! <br /> � �� �� �S�—'1.�07 _ � <br /> IPhona ` Email <br /> L _ <br /> I, tne`Jendor, agre2 to receive!he Back�a�ater Prevention Device rebate check directly fer the � <br /> insiallation at the abova referenced propery address. By aareeing to receive ihe rebate check <br /> dlreclly, I agree b the follo�a�ing: ; <br /> i. The Bac!n•rater Prevention Devica rebate 2meuni tivill be deduc'ed irom tna finzl involce , <br /> glven to the property c,•✓ner for the instai�ation at the properly address referenced above, if � <br /> lhe toiai ccsl ef the Installation is grzater than the rebate. <br /> 2. I.the Vendor, am a Washingten Stzte lic�nsed contractor. <br /> � <br /> 3. The City of Everett�vilt send a Federal Form 1099 h"ISC to me,the Vzndor, for Backe�ater <br /> Prevenfion Device rebate payments totalinc�more than 5600 oer calendar year, and�vill j <br /> report the same paymenls to the Internal Revenue Service. ' <br /> E <br /> i <br /> II accept the payment of lhe Backtvatar Prevention Device rebate from the City of Everefi pending� � <br /> approval of tha canpleled Bacicwater Prevention Device rebate packaye by the Cliy of Fveretl � <br /> i <br /> ; <br /> t <br /> � <br /> i <br /> �.,��- t� ' <br /> ; <br /> SignatureotContr,.ctor : Date i <br /> � <br /> ' <br /> i <br /> . ` <br /> � <br /> � <br /> i <br /> i <br /> . � <br />