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Contractor Section: <br /> - ..e\A/P,,Y rht k.7%-11()kill 1---L C-1 --1 I i' 0.---cl „,-z- Th-- 7-1f 1 1 <br /> Vendor Name/Business Name/(UBI Number <br /> State of Washington Contractor License Number: <br /> / L.,1,,,,, ',RA f, , ic.‘, , 4, <br /> Vendor Mailing Address City State Zip i <br /> ( �,I�? FIC1— 7iirt 1 y <br /> 4 L 0 L , Y w l r ,� I 3'i f l\/.f��'C!1!'")`Phone Email <br /> , <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <br /> installation at the above referenced property address. By agreeing to receive the rebate check <br /> directly, I agree to the following: T <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final invoice <br /> given to the property owner for the installation at the property address referenced above, if <br /> the total cost of the installation is greater than the rebate. <br /> 2. I, the Vendor, am a Washington State licensed contractor. <br /> 3. The City of Everett will send a Federal Form 1099 WC 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 Internal Revenue Service. <br /> I accept the payment of the Backwater Prevention Device rebate from the City of Everett pending <br /> approval of the completed Backwater Prevention Device rebate package by the City of Everett <br /> ----f7/- --,./ .____.. ,;/D - '2 <br /> l'..-- G----7', ----&.../7477___&9 <br /> Signature of Contractor Date <br /> s <br /> i <br /> 1 <br />