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Backwater Pr�vention Deviee <br /> E� �:ebate Program <br /> ; <br /> Vendor Section (please print): <br /> �- - -----� — ---- - - - - -�--� ---- -------�------ i <br /> _�� t r� � n �y L� Z ���Z�C� C�rt� I ; <br /> u��� -i.L� �L�uP��JI;(�� �i�'i , <br /> I Vendor Name! Business �ame ! UDI IJumber <br /> _C r1 r�tP(�P :r_<�1] �1��---- -- - <br /> State of VVash�ngtnn Contractor LicFm,;e Number � <br /> �'�' fi���5-i1— �v��c-iT �•,n `� �S"'<-�4-� - — i <br /> i Vendor fvlailing Address (;i!y State ?ip <br /> �_�U�'��I - �K`�� _ �Lfvl(;e� CU,�� :��'11.5 (�I�'�wh�il[ . (.u:'v� i <br /> Phonr_ �ntai' —i--:} I <br /> I, the Vendor, agree to receive the Bac�.t•daler Prevention Device rebate r.hech direct�y <br /> foi the installaGon referenced at the Pr:ip�r[y �.�!dr_:ss 13y .�greeiny tc� rec�,ive ihe rob<3'c <br /> cf��eck directiy, I agree to the follo�•dm;� <br /> 1_ The Backtvat�r Prevention �E=�nr�� r::b,�:t�a amuunl c:ill t<� r.iocuc!_:d Lein �he fma� <br /> invoice piven to the Property Or:ncr for the instail�tion at (i�e Froperty A;idr��ss <br /> referenced above, if the total cost of the instalL=3lion is greater than the reba!e. <br /> 2 I, the Vendor, am a lNashington Stale licensed contractor. <br /> � The C�ty of Fvarett �•,�ill send a Feder�l Perm 1099 1�41SC to me, the Vendor, (or <br /> lhe Br�c�<e�;�ter Preven?ion D��vice r�rb.�le {�ayments tolaling more thon S600 per <br /> CFi�Efl(��.' ��i'cf. �11111 1V'�� IUllpl'; �f1U Ii�IP.0 ���i)�IIICIIiS t0 ��li' �lIfCIILi� fVCV(:Illl@ <br /> �(',(V;CC <br /> I �cr.ept (he diroct �'�,iy�nr:nt of tho F:���ka•.�+lei I'r��veniion D��d�r:�� i��he;e frnm the City <br /> �( cvercit �innding approval of the cnm��I��i���' G.�ck�rata Pruven,ion Device icbate <br /> �:ackage hy the C�ty of Everett <br /> , �, <br /> i <br /> , ��. , // ��7�1.ScSti" i L.. // . / ' . <br /> e,a�-.^i � � / � % /> <br /> — —_y _ _ _ � <br /> Srqnatura ni Cont�actnr � � f7i�(e <br /> f�.ig^_ 2 ni 2 <br /> � �.,�. ,ri %':;�-'Ot�l <br />