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� Backwater Prevention Device <br /> R�bate Program <br /> Vendor Section (please print): <br /> �}�� �'�vw� R�,..,�.� t.s_.�_ �o�� - 425�'- oi � <br /> Vendor Name I Business Name! U81 Number <br /> �-,t=�n Pf��Co 3 N '� <br /> S�ytate of Washington Contractor License Number: <br /> 1"l.� �7t)lC Q�'� aNC�HUm� Sll- w✓� • %��`� / I <br /> t <br /> Vendor Mailing Address City State Zip ; <br /> o�C1(y' ^�CXp" C�'2�'7 't^P.�.��'act�Nt S � V'[4Ho�� .<' �,,..+ � <br /> Phone Email <br /> I, the Vendor, agree to receive the Backwater Prevention Jevice rebate check directfy <br /> for the installation referenced at the Property Address. By agreeing to receive the rebate <br /> check directly, I agree to the follo�ving: � <br /> 1. The Backwater Prevention Device rebale amount will be deducted from the final <br /> invoice given to the Property Owner for the instaliation at the Property Address I <br /> referenced above, if the total cost of the instaliation is greater than the rebate. i <br /> 2. I, the Vendor, am a Washing4on 5tate licensed contractor. <br /> 3. The City of Everett will send a Federal Furm 1099 MISC to rne, the Vendor, for ', <br /> the Bacicwater Prevention Device rebate payments totaling mor�� than �600 per <br /> calendar year, and will report the same payments to the lntemal Revenue <br /> Service. <br /> I accept the direct payment of the Backwater Prevention Device rebate from the C`ty <br /> of Everett pending approval of the completed 8ackwater Prevention Device rebate ; <br /> package by ttie City oi Everett <br /> I <br /> I <br /> g �2� - ��- ! <br /> , <br /> Signature o/Contractor Dafe � <br /> I <br /> Revised 9/3/2014 Pag= 2 of 2 <br /> � <br />