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L,ackwater Prevention Device <br />Rebate Program <br />Vendor Section (please ��rinl): <br />;- ------ — <br />�`�L„1�6� �LUAI�,UL•f�_ �n;L. � �iUZ ��Z�� <br />---i -- — <br />Vendor Name ! Bus ness Name / URI Numbcr � <br />C_Ar��PGn � [:il-1 �1�5 <br />Slale of Washington C�ntracter License Number: <br />_[�, �, �'��,E ��r�`�l �- �� ��"i v�f\ �l `r5�'�-C(�, --- <br />Vendor Mailiny Address City State Zip <br />i,� � `� - Z� �I - �`,'S`1 � � it I <br />i --�--- �---- K >Lfb I(.0 J �c\�aV1���1�5 /�����v1 `),r1ci � Cu��1 <br />t' <br />Phone Emaii <br />I— --- — <br />I, fhe Vr.ndor, agree to rec:eive the Backwater Prevention Device •ebate check directly <br />for the installation referenr,ed at the Property Address. By agreeing to receive the rebate <br />d;eck dire::tiy, I agree to the following: <br />1. The Eiackwater Prevention Device rebate amount will be deducted from the final <br />invoice given to the Property O�-,ner for the installation at the Property Address <br />referenced above, if the total cost of the installation is grealer ihan the rebate. <br />'l I, ;Le Vendor, am a Washington State licensed contractor. <br />3 Rie City o( [verelt will send a 1=ederal 1=orrn 1099 NiISC to me, the Vendor. for <br />Ine Backwater Prevention Device rebate p�yments totaling more than $600 per <br />r,a endar year, and v;iil report the same pa��ments to the Inlernal Revenue <br />5ervice <br />I�iccepl th�: dir��ct paymenl of th�� Backwater Pr�vention Uevice rebate from tiie City <br />o' Fverelt pendm�� approv��l of the conq�lc:te�d B�ckwate� Prevention Device reba�e <br />package by tlte Glt�f Fver�t <br />or co,irracror <br />Revsed 913.; 014 <br />-�1i`'-��-�� - - <br />Uatc <br />F'agc� 2 0! 2 <br />