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Contractor 5ection: <br /> -- � <br /> MI ` <<a`;il, . �� �(�'t��l-C 2 �'Z � 3 <br /> _�ur�� �___.�I-� ----f�-_�_---- --���-=_�_ <br /> Vendor Name/ Business Name ! U81 Number �J <br /> _.�4"�-�fv o� � ---- — - <br /> Slate of Washington Contractor License Number: <br /> �(�// d�.Ir{nrtis� l�'1/�— �--i,,� l� 9�U$ _ <br /> Vendor Mailing Address Cily State Zip <br /> _ � �T �l�_`�-- Q/7� o_4-r���� 6i�1 L �-v��'Cr,,�4;1c��-�. <br /> Phone Email � <br /> I, fhe Vendor, agree to receive lhe Backwaler Prevention Device rebate check direclly for the <br /> installalion at the above referenced property address. By agreeing to receive the rebate check <br /> directly, I agree to tfie follo�.ving: <br /> 1. The Backwater Prevention Device rebate amounl will be deducted from Ihe finai invoicc <br /> given lo the propeRy owner for the installation at the property address referenced above, i( <br /> the tolal cost of the installation is greater than the rebate. <br /> 2 I, the Vendor, am a Washington State licensed contractor <br /> 3. The City aF Everett will send a Federel Form 1099 MISC to me, the Vendor, for Backwater <br /> Prevention Device rebate payments totaling more than $600 per calendar year, and will <br /> report the same payments to the Intemal Revenue Service. <br /> I accept the payment of Ihe Backwaler Prevenlion Device rebate from the City ol Everett pending <br /> approval of ihe completed Backwater Prevention Device rebate package by the City ot Everett <br /> E. � 3• o� S <br /> Signalure of Coniractor Date <br />