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. i <br /> � <br /> , <br /> . ; <br /> � <br /> i <br /> � <br /> Contrector Section: . ; <br /> --- — � <br /> 1� i <br /> t1('���•�".y-�'�=�c'�_�is��'��� ���..'l_'� LL,c� �c�',_3��;3 � <br /> Vendor Name!3usine s Name I UBI Number <br /> I <br /> �-/ � .L��-�-�-�--�-�-�------ F <br /> State of Washinglon Contractor License Number. � <br /> � <br /> � <br /> i <br /> �(v'�_(� �—G_Cl.i1`��_�,,--�F��13""ff'_. _ �-`�� �.��� i <br /> Vendor Mailing Address City State Zip 1 <br /> 1 <br /> '�- �D�f�4� C��s_C�-��.-�2��_ C������-('�/?�� ; <br /> Phone Email � <br /> i <br /> 1 <br /> -- - !i <br /> I,the Vendor, agree to receive lhe Backwaler Prevention Device rebale chec'c direc�ly for the i <br /> installation al the above referenced property addresa E3y agreeing to receive the rebate check ; <br /> direr.tly, I agree to the following: ' <br /> 1. The Backwater Prevenlion DeviCe rebate amoun[will be deducted from the final invoice I <br /> given fo lhc property o�vner tor lhe installation at the property address referenced above, if ! <br /> lhe total cosl of lhe installation is greater than Ihe re�ate <br /> 2. I, the Vendor, am a Washinglon Staie Iicensed r.ontractor. � <br /> 3. The City oi[verelt will send a Federal Form 1099 MISC fo me, Ihe Vendor, for�ackwat�r � <br /> Prevr.nlion Device rebalc payments lotalin� more than $60D per calender year, and will ; <br /> report thc sd�e payrnenls lo lhc Intemal Revenue Service. ; <br /> I accepl lhe payment of the Backwaler Prevention D�vice rebate from the City of Everell pendin� j <br /> approval of thr, completed (3�ckwater Prevention Device rebale packac�e by the Gity of Everelt � <br /> � <br /> � <br /> �� � _ ; <br /> 1 <br /> � <br /> ���_ ' ���_�. _ _ _� � LS- � <br /> Sir�nature of Gonlraclor Dale � <br /> � <br /> i <br /> i <br /> � <br /> � <br />