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i <br /> Backwater Prev�ntion Device <br /> � <br /> „/�, � ; <br /> Rebate Program <br /> Vendor Section (please print): ; <br /> � <br /> — � <br /> 1 <br /> C�,�Fg_�u.�� Lun� n�h. I r�t �(y OZ �"IZ� ��`� ; <br /> —� ; <br /> Vendor Name/8usinass Name!UBI Number <br /> L F�rnP�n i=. Cl 'll �1�� i <br /> State of Washington Contractor Liconse Number. � <br /> � <br /> �; G . c-� 55�-i i �v��-rr �.A �i k2c,�cc, <br /> Vendor Mailing Address City State Z� ! <br /> �Z`> - ZrJ�i- ��n9� S�rv��e �JCU�hP��'��5 � �vath�r�P , �u�� i <br /> Phone Email i <br /> i <br /> i, the Vendor, agree to receive the Backwater Prevention Device rebate check direcdy ! <br /> for the installation referenced at the Property Address. By agreeing to receive the rebate <br /> check directly, I agree to the following: I <br /> , <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final i <br /> invoice given to the Property Owner for the installation at the Properly Address ; <br /> re�erenced above, if the: total cost of the installation is greater than the rebate. I <br /> 7_. i, lhe Vendor, am a Washington State licensed contractor. <br /> 3. The City o(Everett will send a Federal Form 1099 MISC to me, the Vendor, for i <br /> the Backwater Prevention Device «�bate payments totaling more than $600 per '' <br /> calendar year, and will report the same payments lo the Intemai Revenue � <br /> Scrvice. ' <br /> i <br /> � <br /> I acr.ept the direr.t payment of tlie Bactcwat�r Prevenlion Device rebate from the City � <br /> of Everett pending approval of the completed E3ackwater Prevention Device rebate <br /> packaye by the �jty�f Everett <br /> - !" i <br /> � /.. , <br /> � , <br /> �-`���__"_ -- —--- — -- -- ����_ i <br /> Si�natw_ of Confractor Dale <br /> i <br /> kevlse:i 9/3I2014 Pa�r. 2 nf 2 ' <br /> - . � <br />