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I � <br /> 1 � . <br /> . Back�rater Prevention Device <br /> � � Rebate Program <br /> Vendor �ection (please print): , <br /> �_�wPB6_u.�s P��w�b�,�c, . In�c . �p�2 ci 2 �o �'-I�t`-' <br /> Vendor �lame I Business Name/ UBI Number <br /> Cd1-rwPBO �q ��1 jn S - <br /> State ef VVashi gton Contractor License Number: <br /> P. U � �b� 5s�r � ���— t,.-�- Gl�zat� <br /> Vendor Mailing Address City State Zip <br /> ��-5 -Z5�-3 8ti� Serv�cP�cc..�p�ell� � � , ;,,. <br /> Phone . Email <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate check direcliy <br /> for the instailation referenced at the Property Address. By agreeing to receive tlie 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 instaliation 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 State licensed contractor. <br /> 3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for _ <br /> the Bac;kwater Prevention Device rebate payments totaling more ihan $600 per <br /> calendar year, and will report the same payments to the Internal Revenue <br /> Service. <br /> � accept the direct payment of the Backwater Prevention Device rebate from the City <br /> of Everett pending approvai of the completed Backwater Prevention Device rebate <br /> package b City o -vereti <br /> 6 Z � �� <br /> Sig ature o/Confracfor Date <br /> I <br /> I <br /> i <br /> � <br /> i <br /> i <br /> Revis�d 9/312U14 Page 2 of 2 <br />