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, <br /> Backwater Prevention Device i <br /> _ f�ebate Program ' <br /> Vendor Section (please print): <br /> � <br /> C �,�F6�t.�� �, n� t __�-_, (y �1Z�.� �'1�`"� <br /> - � _.=___}_���_,�!r.,� U�L _ <br /> Vendor Name /F3usiness Name 1 UBI Number i <br /> LAr�1P�jP _L (d � 1 �'1�-- - ------ -- <br /> :i12te o(Washington Contractor License I�urnber. <br /> _�, � ���`j5_l j_—_ �v�1'�i i _�_�:�� _ ����-���, <br /> Vendor Mailing Address City State Lip � <br /> �_15 " 2���i- 5'�"`�� SE'-fV�Ct' �> C��.m jC'I�5 �I���vlb�rlc <br /> Phone -- - - ----�----t---�-'c.u�� <br /> Email <br /> �- — ------- ------- - <br /> I, the Vendor, agiee to receive lhe F3ackwater Prevention Qevice rebate check direcliy <br /> for lhe installation referenced at the Pmperty Address. By agreeiny to receive the rebale <br /> r,heck directly, I agree to the following: <br /> 1. The Backwaler Prevention Devir.e rebale amount will he deducted from the (inal <br /> invoice g�ven lo the Property Owner for the installation at the Property Adtlress <br /> referenced above, if the total cost of the instailation is greater than the rebate. <br /> 2. I, the Vendor, am a i��ashington State licensed contractor. <br /> 3. The City of Everett will send a Federal Form 1099 A415C to rne, the Vendor, for <br /> the Baclavaler Prevention C)evice rebate payments totaliny more than �600 per <br /> c<ilendar year, and will renort the same paymenls to the IMernal Revenue <br /> Setvice. <br /> i ac::ept the direct payment of the Backwaler Prevc�ntion Device rebate from the Ciry <br /> of Gverett pending approval o( the completed 13ack�vater Prevention Device rebate <br /> pac'<a � y1 ie City of Fyerett <br /> �/ / ' / ' _ <br /> � � � L <br /> � -_�� -��--�_ �-- _- - - =z--����--- <br /> Sr9r��lt/k of Gontr�i tor O.�(e � <br /> L' <br /> Revisen 9l3/,01d �'ag�2 af 7. <br />