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i <br /> I <br /> f <br /> � <br /> I <br /> Backwater Prevention Device i <br /> � � Rebate Program I <br /> I <br /> Vendor Section (please print): ; <br /> � � � , ' ;.-- ; <br /> ( ��?iVt;C��( :���_Ti2v(.!l�`r1_.CtJ��_LC'c_?__ _ _. _ . �L1 F– - �.� (U � � �/ �� I <br /> V '�`--�—� - ' ------..._ _.....-- --- ------ - --- - .. i <br /> endoi Namc�/L3usiness Nam�/ Ul31 Numbci i <br /> ��iG_ rc:(.� ��(n'> N1�' i <br /> � <br /> S(a�e of Washinglon Conlractor Lia:nse Number: 1 <br /> J��>> (�'�iJ ��.,9:'���c (�'IF�t_%ic'�'c'�� lcJ�_'_ � �'!,J •�l <br /> , <br /> � -- --_.---�`--:. ___ __ ; <br /> i <br /> Vendor Mailiny Address Cily Slalc 7_ip <br /> < <br /> ��T:' -.J.S�.'.L' � �C�.J _ /�i�:Cy`�'�i����✓vr��i�N.`��r��'c !i��,�( .C�<"—��\---. I <br /> Phone 6rnail - ---- -- - - � <br /> — --_— —_._—..____-- ----- � <br /> � <br /> I, the Vendor, �yree lo re,;eive the Backwater Pre:venlion Dewce reb.ile check direr,Ily i <br /> for the installation referenced at the Properly Address. Qy apreein,y (o receive Ihe rebale <br /> check directiy, I agree to the following: � <br /> i <br /> 1. The Dackwater Prevention Devir.e rebalr. amount will he dcduGed (ium Ihr. final ; <br /> invoice qiv�n lo ihe Property Owner fnr �hc installalion at thc Properly /lddre.;; ; <br /> re(erenced above, if the tofal cos� of Ihr installalion is yreater Ihan Ihe reba�e � <br /> 7_. I, fhe Vendor, am a Washinglon >tale lir.ensed contraclor � <br /> 3. ihe C�ty of Fverell �vill sc:nd � Federal I=orni 1099 �41SC lo me, the Ven�ioi, for � <br /> Ihe f3ackwater Prevention Devir.c rebatr; payment, lolaliny rnorc ihan $G00 pci � <br /> calr,ndar yr.ar, and will report lhe samc paymenls to ihe Inlcrnr�l Ilevenue <br /> Service. j <br /> � <br /> I accepl the direcl poynien� oi 1he Bar.kwater Pre.venlion Devir,r. reb,�lc� (ran Ihe Cily � <br /> of Lverelt pendin� ,ipproval o( Ihe complelyd I3ackw,dei Prevenlion I)evia�: reb:ilc i <br /> package hy the Cily of (-vcrell <br /> � <br /> � I /1 / . `-_. 7_ lr � <br /> /'�''��� 'c'�. �'- ( -l_—C:��.����'- �y, —I .� l� , <br /> ..°'iyrmtuicorConhrir.ro, ------_- -_ . I)nr�, - � <br /> i <br /> I <br /> I <br /> � <br /> I <br /> i;i�nr-��il ')Li,'1U1,1 Pnqc7nl2 ' <br /> i <br />