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i I <br /> � <br /> I <br /> � Backwater Preve�ntion Device i <br /> Rebate Prbgram i <br /> i <br /> � <br /> Ventior Section (please print): � � <br /> ----- ' � <br /> C mF6£1.t_��un� iN� In;c , I� UZ -�1Zlo ����1 __ — ! <br /> �-�,----- <br /> Vendor Name! Husiness Name / UBI Number I I <br /> c.�,n,nc3P_��r��s--- — ---�- , <br /> ----- ---- -- -- , <br /> State of Washinglon Con�ractor Lia+nse Number. � � <br /> P�•_U_—�4:�—�J`-^��_ �v�k'�-1T_ ' v`'�--`1 �521:�C� __ i <br /> Vr.lndor Mailing Address City I S�ate Zip � <br /> �Z5 _7S9 ;39g S�rv it� FJ�U��eI15 �Iv��b�nc , c��v� <br /> Phbne -- --- Email �r--� I <br /> i --- , ------ i <br /> I, ihe�Vendor, agree to receive the Backwater Prevention Device rebate r,heck direcliy <br /> for ihe installation relere:nced at the Property Address�.,Dy agreeing fo receive the rebate , <br /> r.heck direr.tly, I agree to Ihe followinc�: I I <br /> L� The 9ackwater Prevention Device rebate amoUnt will be deducted from the final � <br /> I invoice given to the Properly Owner tor the installation at the Property Address � <br /> referenced above, if Ute total cost of the install�:ion is greatcr than the rebate � <br /> 2. I, Ihe Vendor, am a Washinglon Siate Iir,enseAlcontractor. <br /> 3.i Thn Cily o( Evere�l will send a Federal Form 1�99 MISC to tne, the Ven�or, for ' <br /> ihn Hackwater Prevention Device rebate paym .nts tolaliny more than $600 per � <br /> ' r.alendar year, and will rc�port the same payments to the Intemal Revenue � <br /> SENIC0. I I <br /> � <br /> I acCept ihe dir�ct payment of ihe Uar,kwater Prevenlion Device rebale from Ihe City ; <br /> of E'eretf pending approval o( the completed Backw7ter f'rev��ntion Device rebate � <br /> pac age by the �.ily�f Fv�rel� � <br /> � � <br /> ` � � i�� I I <br /> � �� �—'� -- — -- ) z.(' LL����— � <br /> Signalu . oi Contractor Datf� <br /> I <br /> � <br /> I � <br /> � <br /> I � � <br /> I � <br /> i Page 2 of 2 � <br /> Revised 9/3l'1.014 ; <br /> I <br />