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� <br />Backwater Prevention Device <br />Rebate Program <br />Vendor Section (please print): <br />C <br />, o L �1Zi� ��l`� <br />Vendor Name / 3usiness Name / UBI Number � j <br />L �1 I?�P ('� A.i. q I�1 �5� S <br />State o( N/ashington Contractor License Number. <br />, L E> ; F>5�i I � v��i i !�-A �l `62c..`(p <br />Venc+or �ailing Address City State Zip <br />��.5 -7 5��i- ?%S`iiS S�fV IC� � CG�'�CI)eIIS l)1�4i1Ii�i1G : ( ��l:M <br />Phone <br />Email <br />I, the Vendor, agree to receive the Backw�ater Prevention Device rebate check directly <br />for the installation referenced at the Property Address � By agreeing to receive the rebate <br />check directly, I agree to the follo��,�ing� <br />The Back���ater Prevention Device rebate amount will be deducted from the final <br />invoice yiven to the Property Owner for the installation at the Property Address <br />reterenced above, if the total cost of the installation is greater than the rebate. <br />I. the Vendor, am a Washington State licensed 'cortractor. <br />The City of Everett �vill send a Federal Form 1099 NiISC to me, the Vendor, for <br />the BackwaterPrevention Device rebate payments totaling more than 5600 per <br />calendar year, and will report the same payments to the Internal Revenue <br />Service. � <br />I accept the direct payment of the Dackwater Prevention Device rebate from the City <br />of [verett pending approval o( the completed Backwater Prevention Device rebate <br />�cka e b the �L f Everett � <br />P" 9 Y_�:1� _ <br />of Confractor <br />Revised 9,'3i2014 <br />�r-y_/5 <br />Da(e <br />Page 2 of 2 <br />