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.,/� Backwater Prevention Device <br /> ' � Rebate Program <br /> Ven,do:r Section (please print): <br /> � �,�F�6�u� _ P��,�,B�N�-i, ��.;c / � oZ `�IZ� �1�t'� <br /> Vendor Name/Business Name/UBI Number <br /> C F�r�iP G� ':C �LI-1 �ln _5 <br /> Stale oF Washington Contractor License Number. <br /> � £��ti 55�-i i �v�^��r wA `�i�57;::cu <br /> Vendor Mailing �ddress Cily State 7ip <br /> � Zc; • 75��i- :�89� Serv�(.e�JcU,MQ��IIs�Iv��1�.���'r � c��� <br /> Phone �mail <br /> I, the Vendor, agree to receive the E3ackwater Prevention Device rebate check directly <br /> (or ihe installation referenced at the Property Address. By agreeing lo receive the rebate <br /> che�k directly, I agree to the (ollotving: <br /> 1. The Backwater Prevention Device rebate amount will be deducted irom the final <br /> invoice given to the Property Owner for lhe installation at the Property Address <br /> re'ierenced above, if the total cost of thc installalion is greater than lhe rebate. <br /> 2. I, lhe Vendor, am a Washington Stale licensed contractor. <br /> 3. The Ciry ol Everett will send a Federal Form 1099 MISC to me, the Vendor, for <br /> th�: Badcwater Prevenlion Device rebate payments to�aliny more than $600 per <br /> calendar year, and will report the same payments to the Internal Revenuc <br /> Service. <br /> I accept the direr.l paymenl of the f3ackv✓ater F'revention Device rebate (rorn the City <br /> of Everelt pending approval of the r.ompleted Backwaler Prevention Device rebate <br /> pacicage by ihe (',�t�.�f Everelt <br /> — �. <br /> � • �_ _ _ __ <br /> ,`\` <br /> '^'—/�/ —+._ ��'� — -- - --- E � � 7 <br /> SignatwL ol Contracfar n�( <br /> i____, <br /> i <br /> Revi;Cd 9/31'I,014 �'�9e 2 of 7. <br />