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� <br /> r`:' Backwater Prevention Devi�e � <br /> � <br /> ���7 ReC�ate Program <br /> �, <br /> ' . <br /> \/endo Section (please print): i <br /> � ----- ----- — -- i --- <br /> C��{�,�FSE:u'���'t.vn�E.L�, Ir.;C__, � �p UZ ��TZ�.� ���`� ' : <br /> ; Vendor Namo /E3usiness Name / UBI Numbe�T 1 <br /> i _ C_�,�����GP_�__�3��1 i1^`> - ----- � <br /> State o`INashin3lon Cnntractcr I_icense Number. � <br /> rr �„ -_ C�� <br /> P_c-�b�:� ���i__�v:���~r_ ��.�� _t ,�s2� , <br /> �__ <br /> Vendor 'J�aiiin� Addres; Git Statc� � <br /> .� Y _ip <br /> Z� - •,� I- �%S`1 l �J C. � 5 �v�t9�)nl <br /> ��— � � c — � j«VI 'C /'� U�M (��+� C,��v� <br /> — — -----�— --�---5-- <br /> Phone Em�il , <br /> � ------- ------------ ---- ------- <br /> I, ,he Vencor, agree t�� receive tiie> Bar,kwater Prevention Device rebate chech directly � <br /> tor the im�tall�;ion referenced at the Property Address; By agreeing to receive the rebate ' <br /> check directly, I agree to the follornr g: I , <br /> i. The Backwater Prevention Device rebate amount �vill be deducted irom the finai <br /> invoice given to the Property Owner for tl�e installation at the Property Address <br /> fl:lEfP.I1Cf.(� 3I)UVP„ I� IIl@ ,otal cosl of the instailation is greater than the rebate. � <br /> ? I, ihe Vendor, am a Washington Slate licensed Icontractor. <br /> :i The City o( Lverett �vill send a Federai Form 1099 Iv11SC to me, the Vendor. for <br /> the: E3ackwater I'revention Device rebatc paymenis toialing more than $600 per <br /> c��!enda! year, and �vill repoit the san�e p��ymeiils to th� Internal Revenue : <br /> Survir.e. <br /> I ,�ccepl ihr� ;ifiect p��yment ol tLe f3ai:kvdaler P�evenlion Device rebate from lhe City ; <br /> nf Everctt pendmy tapproval o( thc compleietl E3,�ek��da�er Prevention De��ce reb�le <br /> p.�ckage by thc�ib'-�f �vercll � <br /> / � <br /> � ,; , � <br /> � /' � � � I <br /> -__ ,; _ � ��� /5 , <br /> \� / <br /> _. �- ; � , <br /> - .-- - - ------ - - - <br /> - - ---- <br /> Si,natur: of Conhl�cfo� �- - Dafe I <br /> � ' <br /> �:��w.ed ��;:i,':O1•7 <br /> Page 2 cf 2 <br />