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i <br /> � <br /> ; <br /> ; Backwater Prevention Device � <br /> ; i <br /> �� ; Rebate Program � <br /> j <br /> ! <br /> Vendor Sectionj(please print); i <br /> �-- -'— -- ------- I <br /> C��`��,�Fh��1.L,5_;__�L,;nS ir���_�(r, UL ��Zl� c1�1`� ` <br /> ; Vendnr iVame I [3u,iness Name I U[31 Number i <br /> � C n r���P G P :C_g -l�iry�5 i <br /> S�tale`�of�A�ashington Contractor License Num6er �! <br /> r ' �:�?c:F ���.��_ �vu�ii i�r1_ C'l�� I <br /> Vendor IJailing Addres; Cit State � I <br /> �2.5 - 'LS��i - >''39�� Sc'rv�C�FJCu.�, jells f,.�,�,b,��� � <br /> �—�—ce,� <br /> Pnone Email i <br /> i <br /> '— — — — + <br /> I <br /> I, the Vendor, agree to receive lhe Back���ater Prevention Device rebate check directly i <br /> (r,r the installation referenced at the Properiy Address. By agreeing to receive the rebate � <br /> r,i•eck directiy, I ayree to ihe follo�•,�ing ; <br /> i <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final j <br /> invoice given,ro lhe Property O�vner tor the installation at the Property Address 1 <br /> reierenced at�nve, i( the total cost of the installation is greater than the rebate. � <br /> 2. I, lhe Vendor,;am a VJashington State licensed contractor. � <br /> 3. Thc City of 6verett v.�ill send a Federal Form 1099 NIISC to me, the Vendor, for I <br /> the [3ack�a�ater Prevention Device rebate payments totaling more than $600 per � <br /> calendar year, and �vill report the same payments to lhe Internal Revenue l <br /> Servfce. i <br /> f <br /> i <br /> i <br /> I accept the direct payment of ihe Eiackwater Prevention Device rebate from the City � <br /> of Everett pendiny approval nf the compieted 13ackv,�alcr Pievention Device rebate <br /> package by the (�itj�(E�tt � <br /> / <br /> �`'\' /_ . . � \ ; <br /> -- � - ----- �-,�c,g/i s � <br /> S�gnatu ofConhacfor Date � <br /> I <br /> I <br /> I <br /> i <br /> i <br /> � <br /> Page 2 of 2 ; <br /> Revised 913I2014 i <br />