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1 <br /> 1 <br /> i <br /> x <br /> I 3 <br /> 1 <br /> a <br /> ry <br /> i <br /> Contractor Section: <br /> Vendor Name I Business Na •a I UBl Number <br /> a <br /> State of Washington Contractor License Number: <br /> 1 7 Lip <br /> :1"-5 L( 'T S r Sf7$ .. o� - <br /> u „t S� l k Gt4Y-- --C1 U <br /> i <br /> Vendor Mailing Address City State Zip I <br /> Li '. S. 76, c--36.G f%fe,'1T6�' /1-1 (2-,1(f.1\ -7(Lit"1�ji't�l . ccs<—t <br /> Phone Email i <br /> i <br /> 1 <br /> 1,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, 1 agree to the following: t <br /> 1_ The Backwater Prevention Device rebate amount will be deducted from the final invoice 1 <br /> given to the property owner for the installation at the property address referenced above, if 1 <br /> the total cost of the installation is greater than the rebate. <br /> 1 <br /> 2. 1,the Vendor, am a Washington State licensed contractor. i <br /> 3. The City of Everett will send a Federal Form 1099 MSC to me,the Vendor,for Backwater <br /> Prevention Device rebate payments totaling more than $600 per calendar year, and will 11 <br /> report the same payments to the Internal Revenue Service. l <br /> 1 <br /> I accept the payment of the Backwater Prevention Device rebate from the City of Everett pending i <br /> approval of the completed Backwater Prevention Device rebate package by the City of Everett 1 <br /> i <br /> a <br /> Signature of Contractor Date , <br /> i <br /> 3 <br /> 1 <br /> 3 <br /> I <br /> I <br /> I <br />