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1 <br /> ' Backwater Prevention Dev�ce � <br /> E�ebate Program <br /> Vendor Section (piease print): I <br /> C mFF>Et.t-'��nti u�( � I n.�t_—,�_�Ji U'�- c (Z�` c� 1� <br /> Vendor Name /Business Name! U81 Number <br /> - C �,m�Gl�_L_����1'+5--- ----- --- ------ � <br /> Stale of Washington '. ontractor License Number: <br /> (1 L, �7 � <br /> J'_�:_ L��Lf ��J'-� �Vii�l I --- 1....r\ `�� 55 �L_ ' --- . <br /> Vendor tvlailing Address City State Zip <br /> �j=/� �l- _5`,`K`��� 5�'_NI(„t' �J (�c.\✓H�I)C���S ���4t1`)�v1C� . Cu�v� <br /> Phone ---- _ Einail --- _�� � <br /> I, the Vendor, agree io receive ihe Backwater Prevention Device rebate check directly , <br /> (or the installation referenced al 1he Property Address. f3y agreeing to rer.eive the rebate <br /> check directly, I agree to thc following: <br /> 1. The f3ack�vater Prevention Device rehate amount will be deducled from the final <br /> invoic.e given to the Preperry Owmer (or the installatinn at the Property Address � <br /> referenced ahove, if the total cost of the. instailation is greater than the rebate. � <br /> 2. I, the Vendor, am a Washinpton State licensed contractor. <br /> :1. The City of Everett wili send a Federal Form 1099 f�11SC to me, the Vendor, for <br /> the eackwater Prevenlion Devi�c rebate payments totaling more than $600 per <br /> calendar year, and v.�ill report tlie same payments to the Internal Revenue <br /> 5civic�. <br /> I ar,cept ihe direct p��yment of the Ciackv,�ater Prevention Device rebate from fhe City <br /> o( L=verett pending approval n(lhe completed Bar.h��,�aler Pievention Device rebate <br /> package by the Ciry of Evcrett <br /> - - -� ='"' - --- ---- 1�(/-� S �-'�-- ` <br /> Sr,qnah of Conlractor Da1e j <br /> i <br /> i <br /> ; <br /> Page 2 of 2 � <br /> Revised 91312U14 � <br /> i <br /> I <br />