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Backwater Prevention Device <br />Rebate Program <br />Vendor Section {please print); <br />C•��,�F6E_LL��_�_�n�iiJ(•�,_ Ir��c. ��� �"li..lo �Cj`.� -- <br />Vendor Name I Dusiness Name / UBI Number <br />«�;nr�p_r��_ � � � _ <br />Stale of Washington Contractor License Numher: �— <br />_F:_L• i)c:ti ��� F��.�i; ir-A �l� <br />Vendor Mailing Adti;,:ss City State <br />`'tZ5 ''L5`i- ='%S9FS S��r�i � Z�P <br />' �e � Cu��l�e l Is � o!, �.� ��, �� . , :...,, <br />Email <br />I, the Vendor, agree to receive the t3ackwater Prevenfion Device rebate check directly <br />for lhe installation referenr,ed at the Froperty Address By agreeing to receive the rebate <br />check direr.tly, I agree to the following: <br />1 lhe �ackw�ter Prevention Devico rebate amounl will be deducted from the final <br />invoice given lo the Property Owner fnr the inslallation at the Property Address <br />referenced above, if the total cost of the instaliation is greater than the rebate <br />2 I, the Vondor, am a Washington State licensed coniracbr. <br />3. The Qily of [verr,tt v✓ill send a Federal Form 1099 NIISC to me, the Vendor, for <br />fhe Backwaler I'revention Device rehate payments lotaliny more than $60D per <br />r,al�ndar ycar, and will report the same payinenls In Ihe Internal Revenue <br />Service. <br />I acr.ept the direr,t payment nf the f3ackNr.�ter Prevcmlion Device rehate from lhe Gty <br />of �verelt pending approvai of tho compleled Rar.kwater Prevention Uevice rebatr. <br />packaye by fhe Gitut�f Everelt <br />_/ �� <br />, �• � <br />_\`` i � ` <br />_ ,. , . _----- ---- —�/ �s_ <br />Srgnaf�1 Confrnr,tor � •Dale <br />Revised 9/3/"1U14 F'i�JC'1 of 2 <br />