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i <br /> � <br /> Backwater Prevention Device <br /> �'� Rebate Prograrn � <br /> , <br /> Verodor ;�ection (please print): � <br /> i <br /> � L f�r�F �i< / � r Q I <br /> � � LUrlM1 I1L(-7i �n1C � Uj �Z ��2-�D I�� " <br /> Vendor Name/Business Namc/ UBI Number 1 { <br /> CAmP(3� L �ai� ,� <br /> Siate o(V�ashington Contracfor License Number: — ' <br /> �, U 6��55�{ i �v��-rr wA `�i�2��c, ' <br /> Vendor Mailing Address ': <br /> �2S ,Z5-�i- -�'�`��S _ S�rv��e�Cu,M betils - l���hb�'��� , cU� ; <br /> Phone Email i <br /> i <br /> I, the Vender, agree to receive the Backwater Prevention Device rebate check directly ` <br /> for the installation referenced at the Properry Address. By agreeing to receive the rebate � <br /> check directly, I agree to the follovding: � <br /> ; <br /> 1. The Backwater Prevention Devic,; rebate amount will be deducted from the final <br /> invoice given to ihe Property Owner for the installaiion at the Property Address ' <br /> referenced above, if lhe total cost of the instailation is yreater ihan the rebate. ' <br /> 2. I, !he Vendor, am a Washington State licensed r.ontractor. ' <br /> 3. 7he City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for � <br /> th� F3ackwater Prevention Device rebate payments totaling more Ihan $600 per <br /> calendar year, and will report the same payments [o the Intemal Revenue <br /> Service, <br /> i <br /> , <br /> , <br /> I acr,ept ih�e direct payment of the E3ackwaier Prevention Device rebate from the City ' <br /> of Evereti pending approval of the completed f�ackwater Prevention Device rebate � <br /> packagc by lhe_�' ( Fverett I <br /> �, ��_ � <br /> _ � <br /> ��, _� � � � --- `l 2'���� ` <br /> --�_-- — ; <br /> Siynatu o/Confracror ' <br /> Dafe i <br /> —_ i <br /> . i <br /> � <br /> � <br /> ; <br /> i <br /> { <br /> Revised 9/312014 P��g� 2 of 2 I � <br /> i <br />