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i <br /> Backwater Preventiun Device ; <br /> Rebate Program � <br /> i <br /> Vendor Section (please print): � <br /> t-1ca�c� �c�.-,-• r�,�,.,�, L�c bo3 -4Z�'—vlCa � <br /> ! <br /> Vendor Nane/Business Name!U81 Number � <br /> N�v,.o PpLgGz�Ny I <br /> State of Washington Contractor License Number. � <br /> hb C'GOX �8`� .51 n=OIA-oiv+� S N �,,,,.�- . `!'�29/ i <br /> Vendor Mailing Address City State Zip ` <br /> ��(� �{-OCe-O`�29 � t��4,���-Car<<<�.-r� �/wr+oo . c�,-r� I <br /> ^hone Email i i <br /> � <br /> I <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly <br /> for the instaltation referenced at the Property Hddress. By agreeing to receive lhe rebate <br /> check directly, I agree to lhe following: i <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final � <br /> invoice given to ihe Property Owner for the installation at the Property Address � <br /> referenced above, if the total cost oF the installation is greater than the rebate. <br /> 2. I, the Vendor, am a 1Nashington State licensed contractor. i <br /> 3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for i <br /> the Backwater Prevention Device rebate payments totaling more than $600 per � <br /> calendar year, and will report the same paymenls to the Internal Revenue ? <br /> Service. � <br /> � <br /> I accept the direct payment of the Backwatar Prevention Device rebale irom the City � <br /> ; <br /> of Everett pending ap;�roval of the completed Backwater Prevention Device rebate � <br /> package by the City o(Everett I <br /> I <br /> __ C,�--�. lU– 2'7– C�Y' I <br /> ` - — i <br /> Signalure of Contractor Date <br /> � <br /> i <br /> . � <br /> � <br /> f <br /> � <br /> � <br /> Page2of2 r <br /> Revised 9/3/2014 ' � <br /> i <br /> if <br /> ! <br />