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i <br /> ; <br /> i <br /> � Backwater Prevention Device ; <br /> � Re�aate Program ; <br /> � , <br /> i i <br /> VendoK Section (please print): � ' <br /> : <br /> � � <br /> C��,�nFg.:t,u �.�n� uL( i n,c . �(y U Z �1Zlo 1��`{ i <br /> Vendor Name I Business Name ! UBI Number � <br /> C_F,n���(3P i= �� ���;_. ' <br /> i <br /> � <br /> State of W(�ashington Contractor I_icense Nwrber. ' , <br /> , �S_ UC'� ���(_�V��17 �--- l�r� r� r�� � <br /> Vendor��Qailiny Address City ; State Zip � <br /> �Z`� -�i�i- >59g S��vi�e�J�a,_h���lls -PI���„b�'���; � ���� i <br /> Phone Email I ' <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly <br /> ror the in�tailation referenced at tlie Property Addressi By agreeing to receive the rebafe � <br /> check directly, I agree to the following: I � <br /> I <br /> 1. Tt�e Backwater Prevention Device rebate amount�viil be deducted from the final � <br /> in��oice given to the Property Owner for the insfallation at Ihe Property Address <br /> referenced above, if the total cost of the installation is greater than the rebate. <br /> 2. i, the Vendor, am a Washington State licensed�contractor. i <br /> 3. The Ciry of Everett will send a Federal Form 10�99 MISC to me, the Vendor, for <br /> thf: Back�vater Prevention Device rebate payments totaling more lhan �600 per { <br /> calendar year, and will report the same payments to the Internal Revenue ! <br /> Service. � <br /> I accept the direct payment of the Back���ater Prevention Device rebate from the City j <br /> of Everett pendiny approval oi the compleied Backwater Prevention Device rebale <br /> package� by th�ity�f Everett ' ; <br /> - / � <br /> '-- ` ; <br /> G__ � <br /> ���,.. ��- � — i ��J� j <br /> Signa(ur.�onfractor � Date � <br /> � ' i <br /> _� ' ; <br /> i <br /> • I i <br /> � { <br /> - I � <br /> . • � � <br /> � � <br /> r <br /> Page 2 of 2 <br /> Revised 9/3,'2014 � <br /> i <br />