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i <br /> � <br /> Backwater Prevention Device <br /> En- Rebate Program <br /> Vendor Section (please print�: ` <br /> i <br /> —._ _______ -- CC + , <br /> (� r�'�?6�i.L� L��11 " I l;( �n1C (J L �`�Z.�U ( � \ ' <br /> � _��--��,---�-�-�'----- - <br /> Vendor Name/ 8usiness Name I UBI Number � <br /> _ c_���,�Gn r�-�i_����� ---- - -- -- ; <br /> State of Washington Contraclor l_icense Numher: i <br /> �%i:: �'t:/- �J��'-1 I �v�-i?�i f t,�r\ --- �I iS�L`�{i <br /> Vendor R6ailir.g Address Cily State Zip <br /> �Z`� �l�i�l- �`•S�i� ---���_V�Ci"IS�jCc��rn����5_ .�Ui��Eh�'� '_:_Cu�v�_ <br /> Phone Emai� ! <br /> --- ----- . . . __-- --- <br /> � <br /> I, the Vendor, agree to receive the f3ackwater Prevention Device rebate check directly ' <br /> (or tlie instailation referenr,ed at the Property Address. By agreeing to receive the rebate <br /> check direcUy, I agree to the follo�ving� <br /> 1. The Backvdaler Prevention Device rebate amount will be deducted from the final <br /> invoice given to the Properry 0����ner ior the installation at the Property Address <br /> re(erenred abnvo, if the total cost nf ihe installation is groater than the rebate. <br /> 2. I, Ihe Vendor, am a Washington State licensed contractoc <br /> 3. The City oi Everclt will send a Feder�l Form 1099 MISC to me, the Vendor, for <br /> the Backwatr.r P�evention Device rebate payments totaling more than $600 per • <br /> calendar year, and will reporl the same payments lo lhe Internal Revenue <br /> Servir,e. <br /> I acc�:pt lhe direct payment of �he [3ack�vater F'revention Device rebate from the City <br /> of G�ercli pendiny approval o( the completed [�ack�vater Preventiun Device rebate <br /> package by the Cit�W( Everetl <br /> _/ �, <br /> ,�_. <br /> ��, - ��v'� _ �/ �I I�.5 <br /> Signafu of Contractor Date <br /> Page 2 0(2 � <br /> RC1'ISP.(��)�,��1I)1�� I <br />