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� Backwater Prevention Device , <br /> �' Rebate Program : <br /> Ven',dor tiection (please print): <br /> � ; <br /> � C ���1'6�u'}_�,;��r���_( I,.;c . ` v.4 c1Z�� ��l`� ' <br /> I Vendor Name � Business Name i UBI Numh� � <br /> C_ Ar»pf�P 1��. "1?�]�S <br /> 5,2te of Washin�ton Contractor License Number. <br /> ^ n ,�.-. C <br /> .�1:_r�F FiSy.l— —,�v::_;i i i=�r� l � <br /> ����� <br /> I Vendor 1�tadiny ;�ddras� City State Zi <br /> ' (- r + {� <br /> ���J - ��I__�.'S`�� �G�(-�1/IL'`'��J C(:G�M����IIS _�I�'Ut I)��1 J : ! �iN� � <br /> Phnne Emal <br /> I, lhe Vendor, agree to receive the Backwater Prevention Device rebatc check directly ! <br /> fer ihe ir,stallation reierenced at the Property Address. By agreeing to recen�e the rebate <br /> check directly, I aqree to the follovding: <br /> 1. The [3ackwater Prevention pewce rebate amounl will b� deducted from the final � <br /> invoice given to the Property O���ner for the inslailation at lhe Properly Address <br /> referenced abovr., if the total cost of the installation is greater than the rebate. ' <br /> 2 i, the Vendor, am a VYashington State licensed contractor. <br /> 3. The City ot Everett will send a Fed�aral Form 1099 MISC to me, the Vendor, tor <br /> the Back�vater Prevention Device rEhate payments totaluiy more than �600 per <br /> calendar ��ear, and K�ill report ihe sar,-�e paymenis to the Internal Revenue <br /> SP.NICC. <br /> I ac.cept the direcl payment of the E;ack�valer Prevention Device rehate from lhe City <br /> oi Everett pending a��proval of lhe completed Backv,�aler Prevention Device rehate <br /> F�ackr�gc by the�.iLy�f Fverett <br /> - ' �-- <br /> ,'' <br /> �� <br /> L /.-- _. � <br /> �.�` /=—y`� � '��'�-�T��— <br /> � `• <br /> . . _L�ca �l �� _' ...� �� ���� ___ ' <br /> Signatu� o(Conlractor Date ' <br /> . � <br /> Rcvised 9!3�20t4 ' P�9e 2 of 2 i <br />