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Contractor Section: <br />Vendor Name I Busine�s Name / UBI Number <br />� �-j� 1`1�Z�_�-(U-�-�'-i-- <br />State of Washinglon Contractor License Number: <br />_��tv__Lc�r.l�►�—QL,--_��/�e_i�f' ��%�'FS��>,�- <br />Vendor Mailing Address City State Zip <br />Xn-r.Y <br />Phone <br />Email <br />I, the Vendor, ayree to ieccive the Backwaler Prevention Device rebate check directty for'he <br />installation al �he above referenced property address. By agreeing lo receive ihe rebale check <br />direr.Uy, I agree �o �he (ollowing: <br />1 <br />2. <br />;i. <br />l he Back�vater Prevention Device rebate amounl will be deducted from lhe final invoice <br />given lo the property owner fnr the insfallatio;i al lhe property address referenced above, iF <br />lhe latal r.ost of lhe installation is grealcr than Ihe rebale. <br />1, the Vendor, am a Washinglon Stalc hcensed contractor. <br />The City of [verett will send a Federal Form 1099 MISC lo me, thr. Vendor, for Backwater <br />Prevention Device rebat� paymenls totaling more than A600 per calendar year, and wi!! <br />reporf the same paymen!s to lhe Intemal Revenue Service. <br />I accepl lhe paynient of Ihe Backwater Prevention Device rebate from lhF City o( Gverell pending <br />approval ot Uie compl�led f3ackwater Prevention Device iebale package by lhe C�ty n( Cveret� <br />C'�..�-'---.. �r l__ - -^-.. ---�- - — -� `- � / <br />�� �'.�_ � �5� <br />Signalure of Coniractor Dale <br />