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Backwater Prevention Devi�e <br />Rebate Program <br />Vendor Spction (please print): <br />_C��� <br />\/endr,, <br />C_P,r <br />state or <br />j(�L,U�4', ' �iJ i�� I �J�y <br />Business Name / UBI Number <br />ington Contractor License Nurnbec <br />`.�5�{i �vc��ii <br />� O Z �� ��, �1�1`� <br />wA `�t $Zc�, <br />Vendor Mailing Address City State Zip <br />�? c�_iJ �l -��%S`��j 5���rV ItC �i� CU�^� .����5 �Vivl h�rl�j' � �u�'� <br />-- -- -� <br />Phone Email <br />I, the Vendor, agree to receive lhe Ciackwater Prevention Device rebate check directly <br />for the installation referenced at the Property Aduress. E3y agreeing to receive the rebate <br />check directly, I agree to the following� <br />1 <br />2. <br />3. <br />The Backwater Prevention Device rebate amount will be deducted frorr the final <br />invoice given to the Property Ov,mer for the installation al the Property Address <br />reierenc.�d above, if the total cost of the installation is greater than the rebate. <br />I, the Vendor, am a 4"�ashington State licensed contractor. <br />The City of 6verett will send a Federal Form 109� MISC to me, the Vendor, for <br />the Bacl<water PrevenYion Device rebate payments totaling more than $600 per <br />caiendar year, and will report the same payments to the Internal Revenue <br />Service. <br />I accept the direct payment of the Backwater Prevention D�vice rebate from the City <br />of Everett pending approval of lhe compieted Backvdater P�evention Device rebate <br />package by the �it�e�f Everett <br />oi Contrar,tor <br />�2-�is' <br />Date <br />Page 2 of 2 <br />Revised 913�201d <br />np.+-xru-.r ,..':rA i'�i� ,e� —".i'��r�a7§T- ' ___ � ` � -1_ .�.-< a�s`^'wSh3stfiE2e sa`x-,',^�" __ � ' , ' . <br />aax f� rr. <br />rwa ��.n...v.....,. .y...�:n.nvuatr:swa.a\�1���aYQa'PW'�J'"•,y....+.Wrw.�xrt.uw+rnbM>41N}YNbiltbNM°A`�em'°'+���'._.,�.wu'•<� *,s �^ni��r,' <br />