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� <br />Backwater Preven#i�n Device <br />Rebate Program <br />Vendor Section (please print): <br />N�rzn P��.:,-•��tit� t_�,e <br />Vendor Name / Business Name / UBI Number <br />i o347-5btla vr��� <br />State of War hington Contractor Licen:;e Number: <br />i-IC2o PPL�ie3nf:C <br />Vendor Mailing Address City S�3.e Zip <br />Po �c�x e�,`� SNG �Dvtn� �� �„��-. 9�z9 r <br />Phone �U� -�h� - d9 � Email •T �" i e, s <br />— — � - t�'r�,•r C'o i � _ CG �%�4ifac� ..C's�n.� <br />I, the Vendor, agree to receive the Back ��ater Prevention Device re6ate check directly <br />for the installation referenced at the Property Address. 6y agreeing :o receive the rebzte <br />check directly, I agree to the following: <br />1. The Backwater Prevention Device rebate amount will be cleducted from the final <br />invoice given to the Property Owner for the installation at the Property Address <br />referenced above, if the t ial cost of tF,e installation is greater than the rebate. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. The City of Everet� will send a Federal Form 10°9 MISC to me, the Vender, for <br />the Ba�kwater Preve�tion Device rebate payments totaling more than $600 per <br />calendar year, and will report the same payments to the Iniernal Revenue <br />Service. <br />I accept the direct payment of the Backwater Prevention Device rebate from the City <br />of Everetl pending approval of the compieted Backwater Prevention Device rebate <br />package by the City of Everett <br />G�/ �.�--- <br />Signafure of Contractor <br />f/ .-/'Z—/q <br />Date <br />Pac�e 2 of 2 <br />Revised 9!3/2014 <br />