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Backwater Prevention Device <br /> � T Rebate Program <br /> i <br /> Vendor Se4tion (please print): i <br /> i <br /> , i <br /> C ���FgEu��_ (��um ,in?t� � I���c . � ;�v ��L �1Zlo �1�1`� <br /> Vendor Name/pusmess Name/UBI Number <br /> �A��,PGn r U_J�I��<; <br /> State of Washington Conlractor License Number: <br /> , L_s . ��� �5'-{ I �u ^�i j 'v�A rl iS 2(..`(G <br /> Vendor Mailing Address City � State <br /> � �. � Zip <br /> � �L5 -7�,� � :�:�9K Serv i�e J�U,����Ils_-�I � �h,'�u. <br /> �,� � . ��,� <br /> Phone [mail i —� - <br /> � <br /> I, the Vendor, agree to receive lhe Back�vater Prevent�ion Device rebate check directiy <br /> for the installation referenced al the Property Address; By agreeing to receive the rebate <br /> check directly, I agree to the folio��ding: ' <br /> i <br /> i <br /> 1. The Backwater Prevenlion Device rebate amount v✓ill be deducted from the finai <br /> invoice c�iven to ihe Property Owner for the installation at lhe Property Address <br /> referenced above, i(lhe total cost of the installation is grealer lhan the rebale. <br /> 2. I, lhe Vendor, am a Washington State licensed contractoc <br /> 3. The City of Everett will send a �ederal Form 1099 (v11SC to me, the Vendor, for <br /> ihe Backwater Prevention Device re6ate payments totaling more than $600 per <br /> calendar year, and will report the same payments to the Intemal Revenue <br /> Service. � <br /> I accept lhe direct payment of the BackwaSer Prevention Device rebate from ihe Cily <br /> of[verett perciiny approval of the compleled Backwaler Preveniio7 Device rebate <br /> package by the 4�Ly�f Gverelt I <br /> _� -- � ��— <br /> �_ f� �; _ _-_I� � �� Zt)/ <br /> Srgnafu� o�lContractor j ! pa`�e � <br /> i <br /> ___ I <br /> � I —• <br /> I � <br /> � <br /> Reviseo 9/3l2014 Pagc 2 of 2 <br />