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f <br /> , <br /> i <br /> i <br /> i <br /> I <br /> � <br /> Contractor Section: � <br /> i <br /> , �,�U�Lu � ���. �� -�l � - v,� � I <br /> ; <br /> Vendor Name!Business Name I UBI Number I_ <br /> L�r1:Ls '�-Gs'�.�_�; ' I <br /> � State of bVashington Contractor License Number. � <br /> � � <br /> i ��7 .U5��4.J Ni= /ti2A1. sv� ;s" l�./I 9�S�;o � <br /> Vendor Mailing Address City Slate Zip i i <br /> r <br /> � v� � ������7 � <br /> I Phone Email � <br /> I <br /> 1 � <br /> � <br /> I <br /> , tnz Vendor, agr�e to receive tne Backv�ater Preven;ion Device rebate cneck direcUy tor the : <br /> installation at the above referenced proUeny address. By aareeing to receive the rebate check I <br /> drecily, I agree to the follo�•�ina: ; <br /> i <br /> 1. The Back�vzler Prevention Device rebate amount n�ill be deducted irom the final invoice � <br /> oiven to the propertq o�vner for ihe installation at the property address referenced above, if <br /> the total cost of the installation Is areater than the rebale. ' <br /> � : <br /> 2. I, the Vendor, am a lNashington State Iicensed conlractor. ' <br /> 3. The City oi Everett e:ill send a Federel Form 1099 MISC to me,tt:e Vendor, for Backeaater j <br /> Prevention Devico rebate payme. is totaling more than SG00 per calendar year, and u�ill � <br /> reUort Ihe same payments to the Internal Revenue Service. i <br /> i <br /> 'r <br /> �'___-_-_-_- ___' _- <br /> ; I accept tiie paymenl of the Ciacktivater Prevention Device rebate (rom the City oF[verolt pondinc� 2 <br /> approval of lhe comp!eted Backe�ater Prevention De��ice rebate package by ihe City of Everett i <br /> ! <br /> i <br /> i <br /> I . �� , ! � f <br /> Signature of Contractor Date � <br /> i <br /> -- — -- � <br /> � <br /> I <br /> ; <br /> ; <br /> f <br /> � <br />