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Backwater Prevention Device <br />Ftebate Prograt� <br />Vendor Section (please print): <br />C�t��,,PgC-�U5 ��.�m iu( In:c� <br />Vendor Name I Business Name / UBI Number <br />C_A��in6P L�l� i�n5 , — <br />��L �12�1� �1��`�i <br />State of V��+ashington_Confractor License_Number. _ —. _.____.___-- ----I <br />�—U L�e��75`i L � v£'�L i i (�r'�. `��-- I <br />Vendor f:4ading Address Cily State Zi <br />�,. P <br />�-tZ5 -?5���- �S�iFS j�t'vi�� J<<�,�,�i�zll5�n�b�'���� , ��,nn <br />Phone Email <br />I, the Venr'or, ayree to receive the Qackti�dater Prevention Device rebate check directly <br />foi the installation referenced at the Property Address By agreeing to receive ihe reoate <br />r.iier,k cirectly, I agr2e to ihe follotving: <br />1 he 13ackt���ater Prevention Device rebate amount will be deducled from the fmal <br />invoice given to lhe Property Ovrner for the installation at the Property Address <br />referenced ahove, if ,he total cust of the installation is greater than the rebate. <br />I, the Vendor, am a Washinaton State licensed contractor. <br />The City of [verett will send a 1=ederal Porm 1099 ft915C to me, the Vendor, (or <br />the Back�vater Prevention Device rebate payments totaling rnore than 3G00 per <br />calendar year, and �vill re��ort the same payments to the Internal Revenue <br />SCNICC. <br />I ar.c;ept �he direc� payment of lhe Dack�vater Prevention Device rebate from the City <br />u( L=verelt pending approval nf the completod Back�•;aler Prevention Device rebate <br />packaye by Ihe City o(,Everett <br />� <br />� ,^' V <br />Signau�c o( Contr��ctor � ` <br />RevicEd 9132U7•i <br />- --- --����1� <br />Datc <br />f aye 2 of 2 <br />