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i <br /> ', Backwater Prevention Device <br /> ' �' � F:ek�ate Program <br /> ! <br /> Ven'dor Section (please print); <br /> _� �—____'S�'__ ' 6 , � � uz �1"Zl� �1�1`k <br /> '_� hr��FbELL Li��i, u� (•�f Ii�� <br /> Vendor Nar�,e/ Business Name ! UBI Number � <br /> L r1 r,'�Q rj�_�_(_'���J^�---- <br /> Slate of Washington Contractor License Number: <br /> ��" '� <br /> _r ' v £�c>E��r'_�_�vu�Yi� i�r\ �l �S�-l�— <br /> Vendor Mailiny Address City State ZiP <br /> �2.�-p 5 -25.`_i - =>n9�S S�rvi�e JCG,M i e { � <br /> , --- PJ iIs �I���t��,�,�; : �,;,� <br /> Phone Email <br /> i <br /> � -- <br /> I, the;Vendor, agree to receive the Backwater Prevenlion Device rebate check directiv <br /> for the installation reierenced at the Property Address. By agreeing to receive the rebate <br /> check directly, I agree to the following: <br /> i The Backwater Prevention Device rebate amount will be deduct�d from the final <br /> � invoice given to the Property Owner for the installation at the Property :lddress <br /> i referenced above, if the total cost of the installation is greater than the re6ate. <br /> 2 ' I, the Vendor, am a Washington State licensed contractor. <br /> 3. ', The City of Eveiett will send a Federal Form 1099 �41SC to me, tne Vendor, for <br /> the Backwater Prevention Devic� rebate payments totaling mor� than $600 per <br /> calendar year, and will reporf the same payments to the Internal Revenue <br /> ' Service. <br /> I �3crept the direct paymeni of the Backwate� Prevention Device rebate from the City <br /> of Ederett pending approv�l c�f the completed Backwatar Prevention Device rebate <br /> pack;age hy the City�f Everett <br /> I - %" ' <br /> � i , <br /> <` ; � _. . -- " -- _. <br /> 1�� 5 � �/zd ,s <br /> , �. �,�. <br /> i � '— ---- --- <br /> Srgni turt: oLContractor Data <br /> � <br /> i <br /> Revised 9/3/2014 Page 2 of 2 <br />