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i <br /> . � <br /> i <br /> f <br /> ii <br /> E�ackwater Prevention Device � <br /> Rebate Program 1 <br /> i <br /> Vendor Section �please print): � <br /> ; <br /> . ( <br /> �I"���1Y�i.1.�5 �L�.A1�Ll;(•� �l�'C � �G �� Z ���-� � 1 \ } <br /> —� <br /> Vendor Name/Business Name/UBI Number j <br /> �Arnpr>P = �an �,ns { <br /> State of Washington Contractor License Number: i <br /> � c: b�x 55� i ���-tr� �,..,� �i�S2c.c� j <br /> Vendor Maili�g Address Cily Slate ZiP � <br /> �tZS - zs��- ��'�sag _ 5�rv�cr��cy,�p�x�►�s ��i��,�n,�,y • c�,� , � <br /> Phone Email <br /> ; <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly ; <br /> for the installation referenced at the Property Address. 8y agreeing to receive the rebate <br /> check directly, I agree to the following: i <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final 1 <br /> invoice given to the Property Owner tor the installation at the Property Address f <br /> referenced above, if the total cosi of the installation Is greater than the rebate. <br /> 2. I, the Vendor, am a Washington State licensed contractor. <br /> 3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for � <br /> the Backwater Prevention Device rebate payments totaling more than $600 per j <br /> calendar year, and will report the same payments to the Internal Revenue � <br /> Servico. + <br /> i <br /> I <br /> I accept the direct payment of ihe Backwater Prevention Device rebate from the City � <br /> of Everett pending approval of the completed Backwaler Prevention Device rebate { <br /> package by the�iW�Of Everett i <br /> - •/ �. <br /> < f,// _ � � -'� ' <br /> `� I <br /> Signaf ol Contracfor Date � <br /> . i <br /> i <br /> I <br /> I <br /> � <br /> I, <br /> I <br /> Revised 9I3/2019 Page 2 of 2 � <br />