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Backwater Prevention Device <br />41M. (debate Program <br />Vendor Section (please print): <br />C6mNEL1.15. 2LuA nUh I tin <br />(A pZ <br />919 1q <br />Vendor Name / Business Name / UBI Number <br />CA6106P T— Cl1-1MS <br />State of Washington Contractor License Number: <br />P u. bUIL 5SL4 i E-V-1-p-L-rT <br />LEA <br />CinL-44i <br />Vendor Mailing Address City <br />L+J- -- 5 df`V tCe 15 <br />State <br />Zip <br />Phone 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 the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington 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 $600 per <br />calendar year, and will report the same payments to the Internal Revenue <br />Service. <br />I 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 ity of Ever It <br />Signal e of Contractor Date <br />Page 2 of 2 <br />Revised 913/2014 <br />