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i <br /> � <br /> i <br /> Backwater Prevention Device <br /> Rebate Program � <br /> � <br /> i <br /> Ve�dor Section (please print): � <br /> I <br /> --._____ ---._. __ _. . _ --------- ----_. <br /> _� , . - ,/� �. _; / , , •-I , i , .. <br /> ' �?E,�i�iL �FliVyr�tirC.i/�` / �, ! <br /> . < '/, ' •.c:J , . C. _ - ��1 �: / �% t <br /> � /a�1� ,. ..--(.(_ _... _... ..__—.___.._..__. } <br /> Vendor Name/ Business Nanie I UBI Number <br /> {�tv�ycG) CG,� ,�//,�� I <br /> -�-- ---------------- ._._..-- ------�—. . . � <br /> Stjate of Washington Coniractor I_icense Numbec �,�� ' <br /> ,/��� ��(S-r�t�.oc'rV c /�4y�t•�ci`c,iV 5 ILJr�—.. - --L&,1 J �: � <br /> (Vendor Mailing Address City Stale 7_ip i <br /> �177 ':�7��' 7`�f).7 ���=1�'C�•,(llC�/�vc��f>/•!%i (�'( !_lt�� ,�.G'.'��_ � <br /> Phone Email — � ` -- � <br /> � <br /> I, the Vendor, agree to receive Ihe Backwater Prevention Device rebate check direclly ; <br /> for the installation re(erenced al lhe Property Address. By agreeiny to reccive the rebate � <br /> check directly, I agre.e to the following: <br /> 1. The Backwater Prevenlion Device rebate amounl will be deducled from the final I <br /> � <br /> invoice given to the Property Owner for the installalion at ihr; property Address � <br /> referenced above, if the tolal cost oi the installation is grealer than ihe rebate. � <br /> 2. i, the Vendor, am a Washinglon Stale licensed contractor. I <br /> 3. The City o(Everelt will send a Federal Fonn 1099 MISC to me, thc Vendor, for 1 <br /> the Backwater Prevention Device rebate paymenis tolaling more than $h00 per I <br /> calendar year, and will report the same payments to the Inlernal Reven�e f <br /> Service. � <br /> I accept the direct paymenl of the Backwaler Prevention Devir,e rebale from ihe City <br /> � <br /> of[verelt pending approval o(tlie completed Backwater Prevention Device rebale i <br /> package by Ihr. Cily of Everell � <br /> � <br /> `/C!(,�)c> '(L C...i�L.G=�— ---- i <br /> Slg/iah�rc ul Conlrar,for U:rtr. ! <br /> . ' <br /> � <br /> I <br /> i <br /> I <br /> � <br /> i <br /> I <br /> P:tr�c Z oi'l. ! <br /> Kcvis��1!Il:i12014 <br /> � <br /> � <br />