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' Backwater Prev�ntion Device <br /> , <br /> Rebate P�-ogram <br /> Veridor Section (please print): <br /> _C''Iqn1P�LL�S t'L A1�IN(�i �niL � Gj 02- �'(Z�p ��� � <br /> Vendor Name J Business Name/ U01 Number <br /> c��,nr�n � �� n �,�s <br /> State of Washington Conlractor License DJumber: � <br /> I <br /> ' � U . �'�U�� 55�-1 I �v-EL•'�-i'f", t,,,q �1�S?�, � <br /> � <br /> Vendor M�ai�lin^g Addres�7s{� City Stale ^ <br /> I "1 ZCl ".L-J��' .'Sr� I`J Scrv�i«J Ca,M ZI� <br /> Q�eI15 PI�,�I)��4 • Cu�� <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 lo receive the rebate <br /> check directly, I agree to the foilowing: <br /> 1. Tlie Backwater Prevention Device rebate amount will be deducted from the fin�l <br /> invoir,e given to the P�operry Owner for the instaliation at the Property Address <br /> referencad above, if the total cost of the installation is grealer than the rebale. <br /> ?_. I, the Vendor, am a Washington S(ale licensed contractor. <br /> 3. The City oi Everett will send a Federal Form 1099 MISC to me, the Vendor, for <br /> the Bacicwater Prevention Devicc rebate paymenis lotaling more than $600 per <br /> •��iendar year, and will report the same payments to the Intemal Revenue <br /> Service. <br /> I accept ihe direct payment of the Backwater Prevention D�vice rebate from the City � <br /> of Everett pending ahproval of the completed Backwaler Prevention Device rebale � <br /> package by th� f EvereR �i <br /> _---- � <br /> i <br /> �'>\. � _ �' � _ _ --- ��Z'Z�if� � <br /> _� <br /> Signafw��Conlrac7or Dafo <br /> Revisecl�g/31�01q Pac�e 2 of 2 i <br /> � � <br />