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i <br /> i <br /> � Backwater Prevention Device � <br /> Rebate Program � <br /> Vendor Section (please print): � <br /> I <br /> --- - - ----- <br /> .- , , . <br /> _ , . i <br /> "i�V�� �:���>Tr�-a�G����r1.1<=1�5_�C-`—�-- - -`'"L%�: .:_....����'_l �/� i <br /> Vendor Name/I3usiness Name! UI11 Numbr�r I <br /> ..L'G'Nc=('� f('✓ /�/(�-' , <br /> ------- ___. _. _ _ -- — __ ___. _-- _ _ f <br /> Slale of Washin�fon Conlraclor Licens�; Number' � <br /> �� � �� �-l��."_:.__ �—._.. ��tit:Y--- . .___./_�����_�/J_. f <br /> I <br /> ''[)� C �y C-���,- 1�c r a r r vn jJ S . . <br /> Vendor Mailing Address Cdy Slalc 7ip i <br /> --' t ' �'�- 'l <br /> � ' . <br /> ��1> -.iP�/- J 1C�7 ��c�, ('� lt�iJ��i:l�%tsv-1 r�e iiuA .CU�•'''� f <br /> ----- r--__" -- <br /> --. . ____. _ . <br /> Phone Email i <br /> I, the Vendor, agree lo receive the f3ackwater Preverzlion Device rebale check direclly I <br /> (or the inslailalion referenced at ihr. Properly Address. By agreeiny to receive ihe rebalr, � <br /> check direcUy, I agree to �he following: <br /> � <br /> 1. The E3ackwalr.r Prevenlion Devioe reba(e amount wili be deducled (inm lhe final i <br /> �nvoice given to the Property Owncr for thr-. installation al thc Property Address I <br /> referenc,r.d above, if lhe total cost of Ihe installalion is groaler Ih�n fhr, rebale. � <br /> '1_. I, ihe Vendor, arri a Washinglon Stale lir,ensed conirac�oi. � <br /> I <br /> 3. The Cily o([verr�tl �vill sc:nd a Pedcral 1=onn 10J9 MISC (o me, Ihc Vendor, (or <br /> thf: Backwater Prevention Device rebate paymenls lotaliny more ihan g600 per ' <br /> calendar year, and will reporl Ihe same paymenis tu Ihc Inlern.il f�evr.nuc; M <br /> � <br /> Scrvice. <br /> I <br /> I ar,cept Ihe direct paynu. of Ihe f3ackwr�ter Prevenlion Devicr. «�bate frnm Ihr c�ity � <br /> of [verelt pendin�� appioval of Ihe campl�,led f3ar.kwaicr Prevenlion D�vir.r, rr.h�le � <br /> � <br /> p,�r.kar�c by Ihe Ci;y nf Evcrett � <br /> � ` • <br /> ';'�!i. ,e�(>�'� C'�_ (?����" �_ fl� ����,5� I <br /> /� - --- — -� _ ; <br /> ,^ir7nr�lu+c of Conlroclor 1),d�� { <br /> i <br /> t <br /> t <br /> i <br /> � <br /> I <br /> P,iq�, 7 nt 7 � <br /> l:oa',�•(I !11:i11f114 � <br /> � <br /> I <br />