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11/05/2p15 02:Bi�M 4253536G07 <br />11/OQ/2015 7:51 P� FAI 429915aJ70 <br />I <br />VQ�dOr Ser.t <br />Statc of � <br />_i� <br />.,-�� <br />Vendor � <br />�ZS - <br />Pho��e <br />MAPLE GFOV[ RV <br />C���oell' c Plu=biaa, Inc <br />Backwater Prevention Device <br />Rebate P�ogram <br />(P►ease print): <br />I Bus;nees Namo / UBI NUm�e� <br />� •,- .. ..� .. <br />ContraCtor License Numbor. <br />Gty <br />JI�N <br />Email <br />U'L <br />State Z;p <br />�, <br />0 <br />PAGE 83/05 <br />fdi ouoa/OOOE <br />�, the Vendor, � grea to receive the Oackwater Prevention Device rebato che �_ <br />ior the Installation reterenCed at the Properry Address. By p9reeing to receive thefe bete <br />cheCk directty,l � agreo to thB foli0wing: <br />1. Tne Back,n��tar PrevenL'on Davir.e rEba(e emount will be deauCed from the final <br />invoico g;ven to th� Properyy pyrnor for th� installstion at tho Nroperty Addreeas <br />referenr�eo abovo, If the totnl cost of U;e inatallotion is greoter than the rebate. <br />2. I, tho Vendof, am a Washinc�(on Stete licensed contraCtOr. <br />3, The City� of Evorett tivill sond a Federei Form 1p9g MISC 2o me, ihe Vendor, for <br />tf�e Backwater Prevention Uevice ro6ete paymonts totaling moro than 3G00 per <br />calonda� year, and will rcpo� ���a seme paymt�ntrs t� the Internal Reventta <br />Service,l <br />lacceotthe <br />o£ Fvere(t p� <br />par.kage by <br />OI <br />RCvISed 9/312014 <br />peyment of th3 Beckwater Prc�venGon Dc�vice �bate Lom the Ciry <br />2pproval of fhe completed Backwa!er Prevor,tion Cevica robete <br />]Lt)f FVnmH <br />I. � � <br />Oufo <br />Pase s arz <br />� <br />� <br />� <br />� <br />N <br />x <br />� <br />