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, <br /> j <br /> ; <br /> Backwa�er Prevention Device E <br /> d R�ebate Program ' <br /> ; <br /> � <br /> ! <br /> Vendor Section (please print): ; <br /> ; <br /> C����r6Eu�� L�;�, i L�c I,.—;c '�-�-� o � � (Z�C� 1�I`� i <br /> Vendor Name !Businrss Name / UBI humber ' � <br /> C_ �n,P G�l_ � I_�-1.��n<> I <br /> State of Washington Contractor License Number. <br /> n <br /> _P, lJ' . L�c:R `J5'-1 I �v�^�-i'i � 'v�-r� �� SS2(.`_(�, <br /> Vendor Mailing Address Gity Stale ZiP j <br /> '-�Z'� - ��i�i- �K9� SC'_fJi 'N� i <br /> ------ � �c��,M�,���i►� �_ i��,�� , ��,� . <br /> Phone Email � <br /> �---- -- -- - <br /> _ ; <br /> i <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly a <br /> fo� the installation referenced at the Property Address. By ayreeing to receive the rebate ' <br /> check directly, I agree to the following: j <br /> l <br /> 1. The Backwater Prevention Device rebate amount vdill be deducled from the final ; <br /> invoir,e given to the Property Owner for the installation at lhe Property Address ; <br /> referenced above, if the total cost of the installation is greater than the rebate. ; <br /> 2. I, the Vendor, am a Wa>hington State licensed:contraclor. ; <br /> 3. ��he City of Everett v✓ill send a �ederal Form 1099 MISC to me, fhe Vendor, for � <br /> the Backwater Prevention Device rebate payments totaling more than $600 per <br /> r,alendar year, and will report the same payments to the Intemal Revenue i <br /> Service. i <br /> � <br /> � ! <br /> I accept the direct payment of the Backwater Prevention Device rebale from the City ' <br /> of Evereit pc:nding approval ot the completed 13ack�vater Prevention Device rebate ; <br /> package by the Gjt�qf Fverett `: <br /> ' �` �� � <br /> <�� -- '�, _�� - i <br /> - � .� _f� �� �i� � <br /> Si,ynatu � oI Contrar,lor Date <br /> ; <br /> � <br /> _ � <br /> 1 <br /> � I <br /> i <br /> ' i <br /> ; <br /> f <br /> f <br /> ' � i <br /> I , Pa e2of2 ' <br /> Re��ised 9I312014 `� f <br /> I <br />