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Backwater Prevention Device <br />Rebate Program <br />Vendor S:ection (please print): <br />� g�siness Name ! UBI Number <br />State of <br />Vendor Mailing Address <br />License Number: <br />City <br />Email <br />��— <br />State Z�P <br />Phone ' <br />I, the Vendor, agree to receive the Backwe terAddress! By agree ngbo eceive tHer etbate <br />for ihe installation referenced at the Prop rty <br />check directiy, I agree to ihe following: <br />pwner for ihe installation at the Property Address <br />1. The Backwater Prevention Device rebate amounl will be deducted from the fina <br />invoice given to the PropeRy <br />referenced above, if the total cost of the installation is greater than the reba e. <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3 hhe BackwaEerePrevenit on Devi ce rebat payments toSaling morehthan $600 per <br />calendar year, and will report the same payments fo the Internal Revenue <br />Service. <br />I accept the direct \paymoval of iheg ompleted Brackwa'ter Peevent onaDevi�ce reb eity <br />of Everett pending app <br />package�e City� verett <br />1 IJ I� <br />Dafe <br />of Contractor <br />Revised 91312014 <br />Page 2 ot 2 <br />