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Backwatei� Prevention Device <br />Rebate Program <br />Vendor Section (please print): <br />�'.�1��1ifjE1l�5�"�-�i;�1i��'J(��_��Ji, �IPG�L ��L�c> �C+�'. <br />Verdor Name I 9usiness Name 1 UB! Nurnber ' � <br />_ C f� i�1i Ci(>—L �I _I�n � --- ---- — — <br />State of W�+ashington Cnnlractor i_icense Number: <br />_�,i_� L)i;�_ r)r>`{L.---�v£i.`-1'I� �.._.t:"f\ �"1 �'St�.l:. � -- <br />Vendorl�qaii�nyAddress [;i�y Stale 7ip <br />� <br />.��-�� � (� - ������---'c'(�d Il.<' J �c��a�� �jC���S � f��:�i1 �hc'14 , Ci:�a'� <br />J <br />Phone Email <br />i Ihe Vendnr, agree to receive the Backwater Prevention Device rebate check directly <br />�:>r the instal!ation referenr,eci al the PropeRy Nddress. By agreeing to receive the rebate <br />�I�eck directly, I agree to lhe follovding: <br />1 The Bark�vater Prevention Device reb.rte amounl �-;ill he deductecl irom the (inal <br />mvoice aiven to :he Property O�:�ncr tor the installahon at the Property A:'.dre;s <br />referenced above, if the total cost of the installation �s grealer than ihe rebate. <br />2 I, ine Vondor am a Washington Slate licensed r.ontractor. <br />ihc City ot Fverctt edill send a Federal �orm 109� fvIISC lo me, Ihe Vendor, for <br />Ihc Dacka�ater Prevent+on Device reh�te paymen�s tot:�ling ntore fhan �G00 per <br />c,al�,�ndar ycar, and �viil repoit the s�me payrnents to thr. Intcrn,il Revenue <br />:>rarvice <br />I accr.pt the r,irer.t p;iyineni of lh�: 11ack�ti�ater Prt:vention Device ral�ate (rntn thi-� Cit�- <br />r�i f v��rcil pendiny approv:�l of lhe comple{ed Bnck���alei Prevenhon Uevice rr.bat�� <br />��;ick.�yc by tlte_Cily�� Cv��i��ll <br />- , �; <br />i � / / ' <br />��- / , <br />�---- - <br />, ��- <br />/- y l� �'���� <br />�_ : . ,. � <br />__-- � '.-- - -- - _— — - <br />5« �n�fu � ul C:a;Lador Uate -- <br />Pn�:u.. 7 nf 2 <br />f2�.�.:is��d :+': . ��14 � <br />