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Backwa�er Prsvention Device <br /> Rebate Program <br /> Vendor Section (ple�se print): <br /> C �,�F��u�5 P�,;,1•,��U c-,_, I�c � �o ��Z `1Z1�_ ���`� __r <br /> Vendor Name I Business Name/ UBI Number <br /> LA�1p(3P L �11-1 E1�� <br /> State o(VVashington Contractor License Numbec � <br /> �, �; fic:�- 5r_-��L__ �v�2.ETi" v�.A `1� _2t`�.�;___— � <br /> � <br /> Vendur fvlailiny Address City State Zip ' <br /> c�Z�j -ZS-�i=�;�5`iiS j�rvi�e � �u�MQ(��IIS- Iv��aITr1 ���v�� j <br /> Phone Crnail � � . <br /> � <br /> I, the Vendor, agree to receive the 6ackwater Prevention De�dice rebate check directly ; <br /> for the installation referenced at the Property Address. By agreeing to receive ihe rebate <br /> check directly, I agree to the following: � <br /> I <br /> 1. Th2 Backtvater Prevention Device rebate amount will be deducted from the final ' <br /> invoice given to the Property O�vner for lhe installation at the Property Address I <br /> referenced above, if the total cost of the installation is greater than the rebat�. � <br /> 2. I, the Vendor, am a Washington State licensed contractor. ; <br /> 3. Th� City of F_verett will send a Federal Form 1099 �41SC to me, the Vendor, for <br /> the Bar,kwater Pre��ention Device rebate payments totaling more than $600 per � <br /> r.alendar year, and will report the same payrr,ents to lhe Internal Revenue � <br /> Service. <br /> I accept the direr.t payment of ri�e Back�vater Prevention Devir,e rabate from the City <br /> of Everett pending approval of lhe compietc.d Backwater Preventton Device rebate � <br /> package by the Cii�.yf Everett <br /> � <br /> / i <br /> /"� — <br /> �'��. - �- ,�,, ` 3 � 3 �s— <br /> Sigr���tu � of Contractor ---`— -— Dale- <br /> I <br /> I <br /> Revised 9/31201�1 �'age 2 ot 2 <br />