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Backwater Prevention Device <br /> � n Rebate Program <br /> Vendor Section (please print): <br /> — — --- -- _--- -- -- --- � <br /> _.. __ - - -- <br /> �IE'iVr'i=z '!�,U'�i�ZvGi-1�-r1 � , � -_" ���o - ('y . � , C> � f . <br /> 1 —_ .cl'�'��'–`��-�--�----��----�-- �u <br /> Vendor Name! I�usiness Name/ U131 Numher <br /> -�G.I{�G�_.. �L�`� ��l L'�—— --- <br /> Stat� of Washinglon Contractor Lir.ensr� Numbei: <br /> � `// �I � <br /> .��l.��l �I`�9.r�lvc� � 7'i� � �t'�fCrN� �. �- ��-(ti� <br /> --�'--�—=-----t��------1_��,� �__-- <br /> Vendor Ivlailiny Address Cily Sta1e 7i� <br /> ��"l'l -5�', 7����—�---��-"'t'rC'�fif�Nrs�'�I�EYl1iTC��'G!lG�.J .�CC��•� <br /> Phone Ernail - — ---- -- --- <br /> I, the Vendor, a,yree to receiv� the Backwaler f'revnntion Device r�bale chr,ck direc�ly - <br /> for the installalion referenced al ihe Properly Address. By agreciny to receive the rebate � <br /> r,heck directly, I agree to the followiny: <br /> 1. T'�e Backwater Prevenlion Device rebate amo�mt will be deduc�cd frorn Ihe (inal <br /> invoir.c given lo the Property Owner for the inslallation at the F'roperty /lddre:;s � <br /> referenced a6ove, if ihe lotal cost of the installation is ,yreater than Ihe rebate <br /> ?_. I, (he Vendor, am a Washing(on Stale lir.ensed conlrar,tor. <br /> 3. The City of [verett will send a Federal 1=onn 1099 MISC to rne, Ihe Vendor, for <br /> thc 13ar.kwaler Prevention Device rebale paymenls to(aling more Ihan $600 per <br /> calendar year, and will reporf thr. sarne paymc:nls lo �he Int�rnal R<:vc:nue <br /> Servicc. <br /> � <br /> I accept lhe direct paymenl of lhe Ciackwaler Prevenlion I)evice reba�a: frorn Ih�� Ci(y � <br /> of Everett pendiny apprnvnl o(ihe complefed Bacicwater Prevenlion Device rebale E <br /> package by thc City oi Everctt ". <br /> � � <br /> � ,� - — <br /> ,',� ��_c� . �_ ,� U,L _ _ _ 7��o j� 5 - <br /> _,'---�,C - ��� ) _ _ __ <br /> �,iynatuic ot Confrar.lor Dalr. <br /> I <br /> I'ni��� 7 ��l 7 � <br /> I;cvc�,c�l JCS17111�1 <br />