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Backwater Prevention Qevice <br />Rebate Program <br />Vendor Section (please print): <br />� C' C � <br />CL��,�Fs�l�`�_��,��,6���r,, I,_c,_ �nOI- —IZI� ( � -- <br />\�endor Narne ! 13usiness Na�ie ! UBI ��umber <br />�. r1 f11�� C� �% Z. ��_ -�L�- -- - --- --- <br />State o( �A'ashinyton Conlractor License Number. <br />. o � � ��' <br />�. C: �i_�—�j�� � �v:-:�c� � i.�r\ _"l i52-[,__�— <br />Vendor hlailiny Address Cily State Zia <br />�.- - � �- <br />�-t2`_� -�_`��i_ �n`,�_—?e��vite�D_C<.�ti,�,i,��lls .iv,�,h,n�, : c��:n � <br />--�— , <br />Phone— ..--- ------ Em�il - ----- ---J <br />I, the Vendor, agree to receive the BacKwater Prevent�on Device rebate check d�rectly <br />for the installation reference�i at the Property Address By ayreeing ,o receive ihe rebate <br />;heck diiectly, 1 agree to :he follo�vma: <br />1 The �ackwater Pievention Device reY�ate amount will be deducted'rom the final <br />nvoire ,yiven lo ;he Property Owrer for lhe instatiation at ihe Property :lddress <br />referenced aLovc, i( tlie to;al cosl of the installalion is greater than the rebate. <br />? I, the Vendor, am � Washingtnn State licensed rontractor. <br />i hr� Cify of Everetl �vill sand a Federal Form 1D99 A91SC to me, the Ven�:or, for <br />Ihe E�ack�vater Prevenlion Devicr. rebate pa��menlc: ;otaling more than $G00 per <br />r�ilundar year. ��nd wtll report :h�t s�in� e paym<-�nts t� the Intornal I�r:venu:; <br />tieivica <br />I,���c��pt lhe diiect pay�neni ��f lhr� [�ackevater Prevent�on DEn�ict: nr;�nt�� frnin Ihr, r;ity <br />��f !_vcretl ��,erdmg appiov,�l �` lhe con����!ctc�f C3�:ck�vafi�r Pir�rc•itiun De�rca� i��h;rte <br />�,ar.kngc hy the �ily�f FveY�:U <br />- �; <br />j ' / <br />��. �' �.�v � � �3 II �o ; i� <br />�� � <br />� � � -- -- -- / <br />Si�n��tu uI �'untia::7or Uuto <br />I':. .�, 2 cf 2 <br />2r-,,�,�ds�. ��a�a <br />