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Backwater Prevention Device <br /> E� �T Hebate Program <br /> Vendor Section (please print): <br /> � ' ' ' — -- /- _ _ <br /> t��[�'.Li� =b�+�'i�ZcyGil�`� .�,���Lc�=��------(- � � i�:— _ L'� / / _.. � /.5... <br /> �=-�-- — <br /> Vendor Name / C�us�ness Name!UI31 Number <br /> ��i[?Nc`G'7 �fES �LIW _-----. .�--- — <br /> State of VVashinqlon Conlrac(or License Number <br /> q�)J t'. .,�- Q 7 r <br /> / � //'� �h?a'��V C� r�C � ' � (.C..t ------ �" G_'J 4�� <br /> ��"' /I[ vC'iJ5 �� Y <br /> Vendor Mailing Address L'ily Sla(e Zip <br /> �(Z> -5�7- 7`/t�S' {�.�-_/-�C��inN�-�:l'/��,usr ?�ci�e,d .Cc��..�� <br /> Phone Email -- -- --- _ <br /> I, the Vendor, agree to receive the Backtivater Preveniion Device rebate check direr,Uy <br /> for the insfallation referenced at the Properly Address By agreeing to receive the reba�e <br /> check directly, I agree to the following: <br /> 1. The f3ackwater Prevention Device rebaie amount will be dedu�;ted (rom Ihe final <br /> invoice given lo Ihe Prnperty Owner fr�r the installalion at lhe Properly Addres; <br /> referenced above, if lhe total cost of the inslallation is greatr-,r than lhe rebate <br /> ?_. I, the Vendor, arn a Washington Slafe licensed conlractor. <br /> 3. 1 he City o( [vere;t will send a Federal Form 1099 YllSC to me, Ihe Vendor, for <br /> the Baclovater Prevention Device rebate payments totaling more than $600 per � <br /> calendar year, and will report Ihe same payments to the Inlernal Revenue <br /> Service. <br /> I accept the dirPcl payment of lhe [3ackwalcr f�revention Devir.e rehate from the City <br /> of Everelt pendiny approval of the compleled C�ack�ti�a(er Prevention Dr.vice reba�e <br /> package hy iF,e City af �verelt <br /> � , 1 <br /> ��r,�I.�LLU(r C� ���.�L�' ------- �J � �_�5 <br /> S�gn,�t�ue olCon6aclor D,�l�� � � <br /> Rvp 2n12 <br /> Rcvi:r.d �fi:!l,_'O 1�: <br />