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ev4Backwater Prevention Device <br />w <br />TT Rebate Proaram <br />Vendor Section (please print): <br />C�n�r6�L�'S PLtin�Bhoh� Inc (�OZ 1Zly cj 1`� <br />Vendor Name I Business Name 1 UBI Number <br />State of Washington Contractor License Number: <br />U %sic 55L4I ff viQ -(I L, -A OS2-1- ; <br />Vendor Mailing Address City State Zip <br />�Zr7 Zirl- 55q! SL'fVl(�'��Gror���1�5� I�'N1�Tr1y�ij'✓� <br />Phone Email <br />I, the Vendor, agree to receive the Backwater Prevention 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 will be deducted from the final <br />invoice given to the Property Owner for the installation at the Property Address <br />referenced above, if the total cost of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington Stale licensed contractor. <br />3. The City of Everett will send a Federal Form loge MISC to me, the Vendor, for <br />the Backwater Prevention Device rebate payments totaling more than $600 per <br />calendar year, and will report the same payments to the Internal Revenue <br />Service. <br />I accept the direct payment of the Backwater Prevention Device rebate from the City <br />of Everett pending approval of the completed Backwater Prevention Device rebate <br />package by the City of Everett <br />of Contractor <br />Revised 902014 <br />2/20115 <br />Date <br />Page 2 of 2 <br />