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Backwater Prevention Device <br />Fl/F F T Rebate Program <br />Vendor Section (please print): <br />2 n �) <br />ldor Name / Business Name / UBI Number <br />ivNc%'S CIF)45- )QIJ <br />State of WashinQlon Contractor License Number C� y1- <br />AC) 3 �/! �' /t-j9 ,q cr G!} d�= /; i<o1Ci,V s. lU r¢ —_Lg'G - <br />Vendor Mailing Address City State Lip <br />NZ5 S�S'7' 7//8.'j i�t</-'t C'fiE/�yd�Ct;NiT�c�.lit�,U CGr✓� <br />Phone <br />Email <br />I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly <br />for the installation referenced at the Property Address. By agreeing to receive the rebate <br />check directly, I agree to the following: <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 <br />referenced above, if the total cost of (lie installation is greater than the rebate. <br />2. I, the Vendor, am a Washi.-igton State licensed contractor. <br />3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for <br />the Backwater Prevention Device rebate payments totaling more than $60J per <br />calendar year, and will report the same payments to the Internal Revenue <br />Service. <br />accept the direct payment of the Backwater Prevention Device rebate from the City <br />of Everett pending approval of the completed Backwater Prevention Device rebate <br />package by the City of Everett <br />ignature of Contractor Dafr, <br />Pape- 2 � f ' <br />Ruvis'nd 9/3/2014 <br />