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Backwater Prevention <br />Device <br />, <br />OIL Rebate Program <br />Veni <br />or Section (please print): <br />C'I <br />0'L�I�j`{ <br />Ve <br />dor Name / Business Name / LIBI Number <br />St, <br />to of Washington Contractor License Number: <br />i <br />C,. %r. 55'i F-V'c�;il" <br />L, A <br />Vendor <br />fiILS <br />Mailing Address City <br />25ri- :g9�S 5eri/l(-eO� m <br />State Zip <br />Ie <br />� Its plwvtb�q <br />Ph <br />pne Email <br />`—�— <br />I, theilIVendor, <br />for th <br />agree to receive the Backwater Prevent <br />installation referenced at the Property Address. <br />on Device rebate check directly <br />By <br />check <br />directly, I agree to the following: <br />agreeing to receive the rebate <br />1.' <br />The Backwater Prevention Device rebate amount <br />will be deducted from the final <br />invoice given to the Property Owner for the instillation <br />referenced above, if the total cost of the installation <br />at the Property Address <br />is greater than the rebate. <br />2. <br />I, the Vendor, am a Washington Stale licensed <br />ontractor. <br />3.; <br />The City of Everett will send a Federal Form 1099 <br />the Backwater Prevention Device rebate <br />MISC to me, the Vendor, for <br />I <br />payments <br />calendar year, and will report the same paymen <br />totaling more than $600 per <br />s to the internal Revenue <br />Service. <br />I acctvt <br />JBrett <br />the direct payment of the Backwater Prevent <br />on Device rebate from the City <br />of E <br />pack <br />pending approval of the completed Backw <br />ge by the f Everett <br />ter Prevention Device rebate <br />--^ <br />Signitw <br />/i �/ <br />of Contractor <br />Date <br />r: <br />Revised <br />i <br />i <br />/3/2014 <br />Page 2 of 2 <br />