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E{/ F. TT <br />Backwater Prevention Device <br />Rebate Program <br />Vendor Section (pleasc prinl): <br />� . . . � � � ,I�;. <br />_ <br />-- <br />r��.4 -:�� ;,,u;,���:�,��� -; -�.�� � . � t�� - C��� <br />Ui-�.s— �-------- - `' � ---- -- - '- --- - ---..._. . __ <br />Vendor Namc / Businr.ss Namc / Uf�l Number <br />j�;(;.r-Ic:�'-J �ff'�'.: ��ll`'�-- .._--- --�--------- ----... . <br />Statc o` VJashinglon Conlracloi Licr:nse Numbcr <br />1%� / ji �.i ' ��/ i.. c r /l'/l �� ,i! <br />�� .�(--l�.S.���--`--��`Yc�-�_�c ��_c�iv� _(�)rY---�� "•!.J ,. <br />_.—. _L—__._..�� — <br />Vendor biailing Address Cily Sla(e Zip <br />i �i�: �J�•: � /��t�.�^ fj0�t lJl �l�/`�!`C���f''�1�'iClLllE�.�i ����-�•'��� <br />' "'—_ '�___— ' _. . _' "_'__'—". _____—__ " <br />Phone Lmail <br />I, the Vendor, ayree to receive the Backwater Pieveiition Devir.e rebate check direr.tly <br />for lhe installation re(erenced at the Prnperty Adr;ress. Hy agmeinq to rer.eive Uie reh,-i:e <br />check direcUy, I agrec to ihe following: <br />1 <br />Z <br />3 <br />The E3ach���ater Prevention Device rehale .inwuni v�ill be deducled (roiri Ilie fin:�l <br />invoice yiven to tlie Prope�:� Ov.�ner for Ihe insta!I��tion at Uu: Property Addri�;, <br />re(rrenced ai�nve, if the lotai cost ot ihe instaGation is ymaler lhan the rebate <br />I, the Vendor, am a Washinyton Siale lir.ensed conira�loi <br />The Cily o( I verrlt will sr�nd ,i Federa�l Form 1099 A415C to rne, Ihe VCIICIOf, IOf <br />the f3ar,kwatcr Prevc:nlion Device reb�ite p<iyments Iofaling more th�n $60D p�;�r <br />calendar year, and will report lhc s�ime paynir.nts to �hu In(crn;il R�.venue <br />Servicc. <br />I aecr.pt the direr,l paymen; o( Ihe Qackwaier f'�c�vention Device ieb�ite (rcim lhe City <br />of [vere�� pcnding �ipproval n( �he comph�led Ei,ickwalcr I'revcntion De�.icc r�halc <br />package by the Cdy of Lvaielt <br />� <br />i 1 , j <br />,l,�F�(� ' (� �..�lLi'-.._ <br />�-- -�-- .— -_ -- <br />t;ri]r�t9hiYc o( Cnntrr�r.lor <br />I:r�r,i•�I `l�:i::'Ol�i <br />C �� <br /><., l� � = <br />/�,/`, ._ <br />f'.'.�i�� ' :�I 7 <br />