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Backwater Prevention Device <br /> T Rebate Program <br /> Vendor Section (please print): <br /> �n�P6EU-��1'L �11 I (�Z�_�NC_� _ / l(I (� Z ���.� CI���1 J E <br /> Vendor Name 1 Business Name/U81 Number � I <br /> CA�,PGA r ���1 i�n� ---------- <br /> Stale of Washington Contractor License Number. <br /> _P:� 6�;� 55�-ii �v��-r- U.�� `t�S2.�c�, <br /> Ve�dor Mailing Address City State 1` Zip <br /> �z�� �-2.)�I- ?�`'S`��j— .. SLI�v�te� C�����C���S -Q�l.'��1U*r1 � . Cu�'✓� <br /> ` f—�---- <br /> Phone Email <br /> i, the Vendor, agree to receive the Backwater Prevention Device rebate check directly <br /> for the instaliation referenced at the Properly Address. By agreeing to receive tha rebate { <br /> check directly, i agree to tiie follo���ing: � <br /> 1. The Back�vater Prevention Device rebate amount will be deductea i�om the final <br /> invoice given to the Property Owner for the installation at the Propeny Address <br /> referenced above, if the total cost of the installation is greater than the rebate. <br /> 2. I, the Vendor, am a Washington State licensed contractor. � <br /> 3. The City of Everett will send a Federal Porm 1099 MISC to me, the Vendor, for <br /> the Backvdater Prevention Device rehate payments totaling more than $600 per <br /> calendar year, and will report the same payments to lhe Intemal Revenue <br /> Seivice. <br /> I accept the direct payment of the E3.ickwater Frevention Device rebate from the City <br /> of Everett pendin� approval of lhe c:.mipieted Backwater Prevention Oevice rebate <br /> par.kage by the�l f Everett <br /> ,�- i <br /> � <br /> `� � �-- _L�/2S i � _ <br /> -- ---(�—- -- <br /> Si,qn��tu �of Contracfor Date <br /> Raga 2 ot 2 <br /> Revised 913l2014 I <br />