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i <br /> � , <br /> � <br /> � i ; <br /> Backwater Prevention Device <br /> �'' T Rebate Pr�ogram � <br /> / <br /> I � <br /> Vendoa� Section (please print): � ; <br /> i — f <br /> C ��nF�,Et,L' L 11 _/t, � � �`-� ' <br /> _.,—._� �, � �c�Tti�c� ��L ��2.1� �l � <br /> ; <br /> Vendor Name/13usiness Name/ UEiI Number ' � <br /> C_��r�1pGl� :I=� �l I nS � <br /> Sfate of W�+ashington Contractor License Number. � <br /> � iS�`�c � <br /> �•�-`_L�tiF �J�`�{L �V�c�I Vrf� � <br /> Vendor fviailing Address Cit � Sfate � <br /> �� ` ZS�I- �:5`j�,( ` Y ` i /� 1 7_ip . <br /> _� `l J�-�rL��LN/-��C��M1.1���IIS- f�I1.'111I�IP�C1 � �UIM1� � <br /> K <br /> Phaie_ — Email � <br /> — i <br /> , � <br /> I, the Vendor, agree to receive the Back�vater Prevention Device rebate check directly i <br /> for the installation referenced al the Property Address! By agreeing to receive the rebate 1 <br /> check directly, I aqree to the following: ' ' <br /> 1. The Back�v�:ler Prevention Device rebate amount will be deducted from the final � <br /> im�oice given to lhe P�opeRy Owner for thc installation al the Property Address j <br /> referenced above, i(the tolal r,ost of the installation is yreater than the rebate. � <br /> 2. I, ihe Vendor, am a Washington State lir.ensetl contractor. � <br /> 3. 1�I,e City of[verett will send a f-ederal Form 1099 MISC to me, the Vendor, for ' <br /> �he Back�vater Prevention Device rebate paym�nts tolaling more than $600 per <br /> calendar year, and wdl report the same payments to the Internal Revenue j <br /> Service. � � <br /> � <br /> �_ � <br /> I accept the direct payment of lhe Backtvater Prevention Device rebate irom ttie ( ity I <br /> of [veretl pending approval oi the complaled Back�valer Prevention Device rebate ! <br /> package by lhe C�f 6vereii ' ; <br /> , ,." � � <br /> � `:- G_ ; �_ ; � ; <br /> — ,- �� � �3� i 5 _ I <br /> Signatu�l. ol Contracfor � <br /> Date <br /> � <br /> ' � ��� <br /> � <br /> � <br /> t � <br /> � � <br /> , I <br /> ' I <br /> i <br /> Revised 9/31201n 'i Page 2 of 7. � <br /> � i <br />