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i <br /> iJ <br /> � I <br /> Backwater Prevention Device � <br /> ; <br /> Rebate Program � <br /> � <br /> � <br /> Vendor Section (please print): � <br /> � <br /> — � <br /> N�ao pi.••M3,N� �� c (�03-4�"- o� � i <br /> — -- � <br /> Vendor Name I[3usiness Name I UBI Number <br /> �}C¢o PPL P�ln3 N1. i <br /> � <br /> SMtate of Washington Contraclor I_icense Number: j <br /> rV �UC f�'�$7 SNbUO^'�1 SFI w� . `/���'J/ � <br /> Vendor Mailing Address City State Zip � <br /> ��� '�O� ^ O/ Z/ _I'1"P/��k-COIIIY.J(`V_�00 . C.OM I i <br /> Phone Email � <br /> I <br /> j <br /> I, lhe Vendor, agree to rec•aive ihe Backwaler Prevention Device rebale check directly i <br /> for the installation referenced at the Property Address. By agreeing to receive the rebatc <br /> check directly, I agree to the following: � <br /> i <br /> I <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final <br /> invoice given to the Property Owner for the installation at the Property Address i <br /> referenced above, if the total cost ef the installation is greater than the rebate. I <br /> 2. I, the Vendor, am a Washington State licensed contractor. ; <br /> 3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, (or I <br /> ihe Backwater Prevenlion Device rebate payments totaling more than $600 per <br /> calendar year, and will report the same paymenls to the Internal Revenue <br /> Service. ' <br /> l <br /> I accept the direct payment of the Backwater Prevention bevice rebate from the Ciry � <br /> of Everett pendinr oroval of the compieted Backwater Prevention Device rebate � <br /> package by the C �verett � <br /> � <br /> ; <br /> `—'�_�Z—__ _ _ 2—/2_— /S` i <br /> � <br /> Signature of Confrar.tor Date i <br /> I <br /> � <br /> i <br /> i <br /> i <br /> i <br /> Page 2 0(2 � <br /> Re��sed sr,iizai 4 � <br /> � <br /> � <br />