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� i <br /> Backwater Preve;ntion Device <br /> � Rebate Pr'I gram <br /> i <br /> Vendor Section (please print): � <br /> � <br /> C�i��r^$Ft..US ��-untiF��,Uhi In�'C � � U'� �12-� �C�� <br /> Vendor I�ame /Business Name/ UBI Number <br /> LA�1P�1� � ��111 �1�5 ; <br /> State of Washington Contractor License Number. i <br /> _ , t> . �c� ��5t-li Ev rt��"i- �i.r.A �'l'$2.E��y <br /> Vendor Mailing Address Ciry � State Zip <br /> ��LS --2.5��i- :�%59� j��'V i(.N� �c��M�����I15 Pl����b.�q . ���v� <br /> Phone Emcil i <br /> I, the Vendor, ayree to receive the Backvdater PrevenGon Device rebate check directly <br /> for the installation referenced at the Property Address.!By agreeing to receive the rebate <br /> check directly, I agree to the following: <br /> 1. The Backwater Prevention Device rebate amount v��ill be deducted from the final <br /> invoice given to lhe Property Owner for the inst211ation at the Property Address <br /> referenced above, if lhe total cosl of the installation is greater lhan 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 IviISC to me, the Vendor, for <br /> the Backwater Prevention Device rebate payments tolaling more than $600 per <br /> calendar year, and wifl reporl the same payments lo the Internal Revenue <br /> Seivice. <br /> I accept lhe direcl paymenl of the 13ac{avater Prevention Device rebate trom the Cily <br /> of Everelt pending approval o(the compieted 6ackwaiter Prevention Device rebate <br /> package by the City�f Everett <br /> �- "��� _ ....__ � ----_ _ : <br /> ` �_ <br /> ��, ' . ^��' 30 Z015_ <br /> Signah of Contraclor Date <br /> i <br /> � <br /> I <br /> i <br /> � <br /> � <br /> I Page 2 of 2 <br /> Revised.91312014 i <br />