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1 <br /> i <br /> f <br /> Backwater Prev�ntion Device � <br /> E� Rebate Program � <br /> ; <br /> Vendor Section (please print): ; <br /> , <br /> — -- --- — i <br /> L� i��FbE'�L�S�LU�11 I �( �n1C ,—LIJJ U Z �_�Z�c ��1 1 — <br /> I <br /> Vendor Name!Biisiness Name 1 UBI Numk�er� ' <br /> c.n��,n��n r_.��,-��5 - -- -- � <br /> Slate o(Washinc�lon Contractor License Number. <br /> '. L �czh�����-1 I �V:;^�i i ; c.�r\ �'l `b21:{� _ � <br /> , ! <br /> Vendor 1�4ailing Address Cit State � <br /> Y Zip . <br /> y�L`j -75��i - 5K9tS Sc't"Vil.e JCc.��M.pI���IS- Iv�t�h;�'� _ . �^,v� { <br /> Phone Gmail ' <br /> � <br /> ------ � <br /> —— i <br /> � <br /> I, the Vendor, agree to receive ihe Backwater Preventjon Device rebale check directly � <br /> for the installation re(erenced at the Property Address!By agreeing to receive the rebale ! <br /> check direcliy, I agree to the following: ' ! <br /> i <br /> 1. l he Backwater Prevention Device rebate amouiit wiil be deducled from the final f <br /> invoice given to the Property o�aner for the installation at the Property Address <br /> referenced above, if the total cost of the installation is greater tfian the rebate. i <br /> 2 I, the Vendor, am a Washinc�ton State licensed Fontractor. ; <br /> 3. The City of E��erett will send a Federal Fonn 1099 NIISC to me, the Vendor, for i <br /> the E3ackwater Prevention Device rebate payments totaling more than $600 per i <br /> r,alendar year, and will report the same paymei�ts to the Internal Revenue ; <br /> Service. ' <br /> i <br /> � <br /> I acr.ept ihe direct paymenl of the Qackwatei Prevention Device rebate from the City j <br /> o( Everett pending approval of lhe completed f3ackwciter Prevention Device rebate i <br /> package by thc�iLu�( Fveretl : � <br /> �� // //, �1_ ! <br /> (/ / � <br /> ` `. � ,' ��.-' � � /�ZU/� i <br /> Srynatu o/Confr3ctor -- — -- Dafo ~ { <br /> i <br /> i <br /> i <br /> — ' —• 1 <br /> � � <br /> 1 <br /> � <br /> i <br /> Revised 9!3l20i4 Pa3e 2 of 2 � <br /> i <br />