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I <br /> � <br /> Backwater Prevention Device � <br /> � Rebate Program � <br /> � <br /> ! <br /> Vendor 5ectiorti (please print): � <br /> _ --�-- I <br /> . , <br /> ' i�1FSE-LL' ' —�,-- ��D �1Z-�U �C�� � <br /> �-�--- ' �- 'n1�yv( Ir�C , oL. <br /> Vendor Name/Rusiness Name/ UBI Number � I <br /> C_ A r»P('>P 7-�'LL 11�___ i <br /> State of Washington Contractor�icense Number: ; <br /> �:_�_ '�JS�{ �v£1'..:-�"�-- ' t�F\ �1�5��_ I <br /> Vendor fJailing Ad,dress City Stale Zi � <br /> Z`� - �J�I - �;'S`j � ` � P ( <br /> �— --------�_ Sc.fViLN�Cc� � I)�'��5 �'v�H�)n1q � Cu� <br /> , ! <br /> f honc L-mail --' <br /> --- �— ---�----- – ------- -� i <br /> I, the Vendor, agree to receive the Backwater PrevenEion Device rebate check direcU � <br /> for the installation referenced at the Property A�ldress;� By agreeing to receive the rebate � <br /> check directiy, I agree to the following: ', � <br /> 1. 1"he l3ackwater Prevention Device reb�ite amount will he deducled from ihe final � <br /> im�oice yiven;to the Property Owner for lhe insfallation at Ihe Property Address � <br /> re(err.nced af_�ove, if ihe total cost of the inslallation is greater Ihan Ihe rebate. ' <br /> 2. I, the Vendor, am a Washington State licensed 'iconlractor. E <br /> 3. The City of Fyerett vdill send a Federal Form 1099 MISC to me, the Vendor, for ; <br /> the Backwat�r Prevenlion Device rebate payments totalinr� more than $600 per + <br /> calendar year, and will report the same paymants to the Internal Revenue j <br /> Servire. � <br /> I acce I lhe direcl � <br /> P Paymenl of lhe 13ackwaler Prevention Device rebate from the City i <br /> of�verelt pending f3pproval nf the cnrnpleted Uackwaler Prevenlion Device rebate I <br /> package by the Citkqf Everc�tt i + <br /> - �/ � / � <br /> r�``` / G J"�__--�-� _ � � <br /> � ..���7rL�__ i <br /> Slgrrafwt o/Contr��cta---- -----� D�fe � <br /> I ! <br /> I I <br /> � t <br /> ' I <br /> i <br /> I <br /> i � <br /> c <br /> , <br /> Rewsed (1/31'l.O1�1 �'��°7��Z <br /> � <br />