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i <br /> Backwater Prevention Device <br /> � � Rebate Progratn <br /> Vendor Section (please print): <br /> � --. � <br /> , .. , _ - <br /> , _ _ , .. . , . .. � � • / ; <br /> , . <br /> ( l�_iY.Gs'�_�`�`'���.�c.�i�_.J_�._�� iC� '. _ .. r•.C�/ - /. �- 1 <br /> _ - --- ------_. . . <br /> Vendor Narne I Business Nanie I UE31 Number <br /> - ,,, � ,..- � . �: <br /> if-.t�lc(. _� � . � <br /> -i----- —��— � �=---- . . - -- ------_ --- --. . . <br /> Slate of Washington Conlractor License Nwnber: <br /> �� ' �� � < ./- i ,;" �.� <br /> ���� �;.9_i`V�_ , 1�i' i'rr _��r�N-�-l�'=��-----LS(J--� — <br /> Vendor Mailiny nddtess Cily Stale Zip <br /> �j j; -7��;��' �'���7 _ir_Cr`('���i/�NcdF'�fbV`ii t..'t_110A� .C�i_.•✓�... <br /> Phone Frnail -- <br /> I, the Vendor, agree to receive the [3ackwater Prevention Device rebate check direclly <br /> for the installation referenced al the Prc�perty Ad�iress By agrecing to reccive the rebate i <br /> check direclly, I agree to ihe following: <br /> 1. The (3ackwater Prevention Device rebate amoun� will be deducted (rorn Ilia: final j <br /> invoice given to the Proper�y Owner for ihe mstallation af thc Property Addrr_:;s � <br /> roferenced above, if the total cost o( the installation is yrealer ihan lhe rebnte <br /> 2 I, the Vendor, am a Washiny�on Stale licensed conlractor. <br /> 3. ihe City of �verelt ta�ill send a Feder�31 (=onn 1099 h41SC to me, Ihe Vendor, for <br /> th� Backvdater Preven(ion Device re6ate paymenis to�aling morr �han Sf,00 per <br /> calendar year, �nd �vill reporl the same payments to Ihe Inlernal Revenuc <br /> Service. <br /> I <br /> i <br /> I ar.cept the direct payment of the 6a�.kvrc�ter Prevenlion Device rebate irom lhe C:ily � <br /> o( f_'verelt pe nding approval o( ihe completecl (3�ickw.ter Prevention Or�vice rehate <br /> packagc by the City of [vcrett <br /> ;;������,,�1 �_�-�'��� �-`_ --- �(����� 5 <br /> .Signrifum. olCnnlr,ic!nr Drd�� <br /> P.up• 2 uf Z <br /> I�r:vr:;�rl !1/.{�lDl�l <br />