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ii <br /> i <br /> ' Ba�kwater Prevention Device � <br /> � <br /> ; a Rebate Program <br /> I <br /> Ven�tlo� Section {please print): <br /> i <br /> I - <br /> C�,�F6Et�.`� L n� �,u�_� I n.�c . � U'L �1Z1� c1�1`� <br /> V�ndor Name f Business Name I UBI Num6e� <br /> _ C.F�m��G P :� q �� ���5 <br /> State i�f Washington Cnntractor License Number. <br /> �—£��`�5�1_ �v�x^��1T ' t�A `1�52�. ��_ � <br /> Vendor Mailing Address Cily State Zip i <br /> �' - i`� ' <br /> �-tZ5 -25 � _ �� S�rv�Ce J �U�pl�c�j��I���t,b,��� , c��� � <br /> Phone Email <br /> � <br /> c <br /> I, the Vendor, agree to receive lhe Backwater Prevention Device rebate check directly <br /> for the installation referenced at the Property Address. 0y agreeing to receive the rebale <br /> check directly, I agree to the following: <br /> 1 . The (3ackvaater Prevention Device rebate amount will be deducted from the finai i <br /> invoice c�iven to the Properiy Owner for the installation at the Property Address I <br /> reterenced above, if the total cost of the installation is greater than the rebate. <br /> 2. I, the Vendor, am a Washington State licensed con(ractor. <br /> 3 The City of Everett will send a Federai Form 1099 MISC to me, the Vendor, for <br /> , the B2ck�vater 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 accepi the direct payment of fhe E3ackwater Prevention Device rebate from the Ciry <br /> of Everett pending approval of the r.omp�eled 8ackwatcr Prevention Device rebate <br /> pack;age by the Citx.�i Everett <br /> - i <br /> / ' <br /> I / i <br /> � ,;�- � <br /> �. F �.--i- _ �-Z'S - ( � <br /> Sign�f • ofContrar.(or ' Dafe <br /> I Page 2 oF 2 <br /> Revised 9/3l2014 <br />