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�� B��ckwater Pr <br />�C� Rebat� <br />Vendor Section (please print); <br />I ('.--�,�f''�ta.� - --) -- �-` ------ <br />I --� - �'�— _� �L���UJ1 � ( � w'C , <br />�--- �. <br />Vendor Name / gusmes; Name / URI Number <br />i_��A ��,P G r�. t=��l i=1 � � -- <br />_ 1_5 __-- <br />Stale of bVashington Conir�Gor License Numbec <br />I 1,_L^ f���_ �:�5-+ L._. �_��'�-r7- <br />Vendor �aJing Addres, Cilv - <br />i �- � r� '�F"[� _ _�%$`i. `- °' r , <br />–�-- -- � 5�_�-� �CN � ���,M <br />Phone Email <br />L----- <br />I, Ihe Vendor, ayree lo receive the Backwater P <br />'ar ihF installation re(er�nc�d �,l lhe Property Ac <br />checl� directly, I a�ree to Ihe follov,�ing: <br />1 T-he Backw�tc:r PrE:vention Device «;bate am <br />mvoice given to the Property Owner (or Ihe ir <br />refernnce�l above, if th� to�al cc�st of the insta <br />: I, Ihe Vendor, arn :� W�shir�gton 51ate license <br />3 flie Cdy o( Fveret� will send a 1=ederal Form <br />the Barkwater PrevenUon Device rebate payi <br />c�lr.ndar year, and will reporl fl��e ,aine payrr. <br />Service. <br />I ar,r,ept lhe direct p�ymenf nf the Rackwatcr <br />of Ev�:�ir.lt �iending a�proval o( the compl��;led <br />p�icknge by ihc City of Ev�r��l <br />Corr�rar,fnr <br />li�.rsnd s�, ��, p,,; <br />on D�vice <br />�arn <br />�_� _ � 12.1�; <br />t� r\ � � x'� <br />LC"�=— <br />6tate �;� - <br />m Device reb�te check dire^tly <br />E�y agreeinc� to receive ihe reLate <br />nl wdl 6e deductr.d from the final <br />ali,�tion al the Property Address <br />tion is greater than Ihe rebate. <br />conliactor_ <br />99 MISC ,n me, the Vendor, for <br />�nts totalii�g rT�ore ihan �600 per <br />d:; lo the Intemal Revenue <br />on Uevice reba�e from thc Cily <br />ter Preventi�n f)��vice rehato <br />��� �%� <br />D��fe <br />Pa0(3 2 n( J <br />