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i � <br /> i � <br /> _ � <br /> Backwater Prevention Device � <br /> Rebate Program � <br /> � <br /> , <br /> , <br /> ; <br /> Vendor Section (please priltt): ' <br /> ; <br /> , <br /> I —,1`1------} ---�—� � � U( � (�.,L-- --U y- ---------- l <br /> r-- ------- -- ' <br /> i� C'. iv�F Ell-' � � i C' CC G <br /> 6 c� �--�--�--� �y--�2� --T ��_ ; <br /> Vmidnr Name / Rusmess Namc / U(31 Numhcr I � <br /> i . _�An,p�_r. �j1�_�]�� i : <br /> — --- ------ — <br /> Sltale of Washington Contractor Lir.ense Number � <br /> � E=�_..C��:.N--r��—��__�v{---r:7i -- - �"-'r� �1 �2c-`{�--- � <br /> Vendor Mailrng Addres� Cdy State � <br /> � p � <br /> �25 - �'—'-_"�`�� ---Sc'�di�e�� �u,�, i��ll5_�I����h�r��_, c��v� � <br /> Phonc Em��l --- I - - � <br /> - � <br /> -- - --- <br /> - ---- — - ----- ------ ------ <br /> I <br /> � <br /> I, ;he Vendor, agree to rer,eive ihe [3ackwater PreventIon Device rebate check directly � <br /> for the instalia(ion referenced at the Property Addressi By agreeing to receive the rebate ' <br /> check tlirer.tly, I agree to the followina � <br /> 1. l he �ar,kwater Prevenlion Uevir.e rebate amoulnt wdl he deduc;ted (rom the final ! <br /> invoice given tu thc F�roperty Owner for the installation at the Property Address <br /> re(erenced ��bove, i( ihr. total cost nf ihe installation is greater than Ihe rebato. { <br /> 2 I, the Vendor, am a Washington Statr. licensed conlractor j <br /> 3 The Cdy o( Eveiett will send a Federal Form 10A9 MISC In rne, ►he Vendor, for i <br /> the Bar.kwaler Prnv��ntion Device rehaie p.iymonis tolaling more lhan $600 per : <br /> calendar yeai, and will report the same paymr,nis lo the Internal Revenue � <br /> Service � <br /> ; <br /> I ; <br /> I �ceepl ihe d:iect payment ot thra ll:ickw;der Pievent on Devir.es rebat�� from Ihe Cily � <br /> of [verett pendin,y apprnv�l ol the completed Hackw: ter f'revi�ntion f.)ovice reha�e + <br /> pack�ye hy ihc��ty r�f P.vcreQ i i <br /> _ - _ , '� ; � i <br /> , `� ' <br /> - '� - ��`� -'"�` - � ___._ _ ( 1 1 � __ � <br /> Siyriah� � o!Caihaclor � ; <br /> P � <br /> � o ro ; <br /> i <br /> I i <br /> � <br /> � <br /> I 1 <br /> 1 i <br /> Ftev�sed 9/3/2014 �'age 2 of 2 i <br /> i � <br />