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. • i � ' <br /> Ba kwater Prevention Device <br /> Rebate Program <br /> Vendor Sec►len (please print): <br /> � <br /> � -- <br /> � <br /> _ C�-w�P P. U.` �Lviw ir��i nl ��,07-_�`� <br /> Vrndor Name /8usiness Na e/UBI Number � <br /> �� n i � <br /> State of Washington Coniract r License Number: <br /> �.0. �np 5��1.� Fv�c111s� wA- qSsZO� <br /> Vendor Mailing Address i Cily State ZiF� <br /> 5-z5�t- �f��i4C �P,. ��;�� c��.nl?r11S•� ��.b��.�6�'� <br /> Phone � Email <br /> i <br /> I, ihe Vendor, agree to receive;the Backwater Prevention Device rebate check directly <br /> for lhe installation referenced�t the Property Address. By agree�ng to receive the rebate <br /> check directly, I agree to the fo lowing: <br /> i <br /> 1. The Bar,kwater Preventipn Device r:bate amount will be deducted from the final <br /> invoice given to the Pro erty Owner for the installation at the Property Address <br /> referenced above, if the total cost o�the installation is greater than lhe rebate. <br /> 2. I, the Vendor, am a Wa hington Sta!a licensed contractor. <br /> 3. The City ot Everett will s nd a Fedaral Form 1099 MISC to me, lhe Vendor, for <br /> the Backwater Preventi�n Dovice •ebate payments totaling more than $600 per <br /> calendar year, and will r port lhP same payments to the intemal Revenue <br /> Service. <br /> I accept ihe direct payment of�the Backwater Prevention Device rebate from the City <br /> of Everett pending approval o� tho completed Backwater Prevention Device rebate <br /> package by th ' of Ev et4 <br /> -- � � 2s � <br /> Signatu olConfractor � Dafe <br /> I <br /> � <br /> i <br /> ' Pege 2 ot 2 <br /> Revised 9I312014 � <br />