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Backwa�ter Prevention Devic� <br />�ebate Prvgram <br />Vendor Section (please print): <br />�� t�1"('j�i,i-�j___r�(.-v�91�UL�_ � f.:Ly�_ �1 �' Z <br />Vendor �Vame ! Business Name / UBI Nurnber � <br />c�n,�Gn � �i��_��s----- — <br />State of VJashington C�ntractor License Number <br />�l:_ £l�� �,"��i�� �v�c-'�i _ i�f\ <br />�1Z.� ��I`i <br />�l?S2Ll��, <br />Vendor Iviailing Address Lijy State Lip <br />�� <br />�`> - Z�i �i -_�5`�iS_ Sc'_i"v iCC �'cu l a�M�i��'�15 plvi� h�c�c Ct,�� <br />- ---- --1 �-=- — <br />Phone <br />Email <br />I, the Vendor, ayre� to receive the [3ackwater Prevention Device rebate check directly <br />for the instailation retcrenced at the Property Address. Ciy agreeing to re�:eive lhe rebate <br />check direr.tly, I agree to the following: <br />1. The fiacktvater Prevention Devir.e rebate amount vaill be deducted from the final <br />invoicc given lo the Property Uwner for lhe installation at the Property Address <br />referrniced above, if the loial r.ost of the instaliation is greatcr than the rebate. <br />7_. I, the Vendor, am a Washingtun State iicensed contractor. <br />3. 1"he City of Everett tvill send a Federal Form 1099 t��ISC ta me, ihe Vendor, for <br />the Back�valer Prev�ntion Device rebate payments totaling more than $600 per <br />calendar ycar, and �vil! raport the same payments to the Internal Revenue <br />Service. <br />I acc�pt tho direct paymenl of the E3ar.kwater Pre�rention Device rebate from the City <br />of Everett pending a��rroval of the comp';.�ted t3ackwater Prevention Device rebate <br />packa,ye by lhr. Ciry of f=verelt <br />�� �/��.,� � <br />Signature o/ Confractor <br />IZeV15Cd 91317�14 <br />_ —J!/.� 3L/s_ <br />IJ`�te <br />Page 2 oi 2 <br />