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i <br /> � <br /> ` Backwater Prevention Device � <br /> � T R.ebate Program � <br /> i <br /> Vendor Section (please print): � <br /> --- -- _ -- ___ ---- _— -- -- _ _ _------ � <br /> � C_'�i��F5L1i'�__f��•�i,�����L(�r l,,x _�__ � (y U L � I� �� �����_ i <br /> ' Vendor Nam� /dusiness Name 1 URI Number ; <br /> � _ c_n��,(%G P r �i i�i-'�^—�-------- - ------ - --- ' <br /> Statc ot J1�ashinylon Conttxtar �icense Nurnb2r . <br /> _ ,i , �' 'i <br /> , . � <br /> � < < �V�{_c�f i/�r� � �$c.C. �—.._. <br /> -:�"--�'�-�`�`� ----- -- - ------- -, � <br /> Vendo� IJla�ling Addre�ss City S�atf� Z�p <br /> ,,�. <br /> ��-5 - l���� - _�'S`�t� _ ._5c'(�Ile �i/ C.c.\�al1i)�'��5 [��v�N�)��1c . ��,v� � <br /> --- --1'--- -�--- --- <br /> f'hune E�mrui � <br /> --- --- --- --_ -- - --- ---- -- ----------- ' i <br /> V <br /> i <br /> I, tht� Vr,ndor, ayree to recewe the Backwaler Prr.vention Device rebale chE�ck direcUy ! <br /> for the installatior fP,fP.fCI1CCCI �I �f1P. P�l1�Cl'1y A(Sl1fCSS E3y �'7C�ff,Clflg (0 feCP,l'J2 �Il@ fP.IlBtB ; <br /> check d�reciry, I agree lo the (ollowiny <br /> 1 The Backwaler Pieventi,,n Dewcr. rebate amount vrill be deducted from the (inal � <br /> Invoic� given to tln� ProF�erty O�vner for the in;tallation al Ihe Property Addr�,s � <br /> r�L�renced ahove. ( Ihe tolal cost o(Ihe ins�allation is greater than ihe re� ate. • <br /> l. I, the Vendor, am a VVashington State licensed contrar.tor � <br /> i I he City of Eveiett will sf:nd a I�ederal Form 1099 tv11SC to me, the Vendor, for ; <br /> Ihr. E3acka��ler Pievention Qev�c�� rebat� payrnents to�alin,y nwre ihan $GOU per � <br /> r.alendar yc�ar, and will report tlie s�mr� payments to the h�lcrnal Revenue j <br /> Service ' <br /> I nccu��� �ho diiect ���aymenl of the Liackw�ter Preveniinn Device rebatn (rnrn the City � <br /> of E:verclt pendiny approval o� Ihe c.r,mplr�l��d Har.kv;ater f'revr.nhon Ucvir,e rehatc� , <br /> pockagc�y the Cil�of f_varr��t � <br /> < <br /> v <br /> � .' 1 <br /> � � `� �"'.~v \-- -- - - - � J7.'��C� , <br /> � <br /> - . .. ._,__ � <br /> _ . �r ,,;, .. - - - - r• - ,- -- , <br /> SiUnature fi(Cnnfrocfur DafA <br /> �•' � <br /> � <br /> � <br /> i <br /> i <br /> � <br /> Paga 2 a(2 i <br /> Rr:wsed�I31201A <br />