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Backwater Prevention Device <br /> Eu Rebate Program <br /> Vendor Section (piease print): li <br /> ; <br /> , _ ' - � - <br /> .� , � 7 � • <br /> / . , _ _� �, �i, <br /> � �. � <br /> �- - ., t f_ ;, � <br /> � �(.CiiYt'c�� ( ��i'v`-'11�`�C-�/�'/`� /E:�� ��'�-- � �(.�''l / <br /> _....... _ _ ._ .- - -- <br /> � <br /> Vendor Name / Business Nai7ie/ UBI Nun�ber <br /> �� . . _ ;. <br /> ���'��rr;�.��7 � (:`i J��.�-� `t <br /> - �._._-� --_---_._------------- _ .... __ ___.- --- ----- ------..__._... i, <br /> r <br /> S#ate of Washingion Coniractor Licens� Nurnbc�i <br /> . <br /> .- <br /> � j� /_ �J � n . � �:-✓_ ,. , r.r,J ��r �sJ <br /> ,�`� _� �1 ��. �:,: c`��-- �1`�-(�� l i c vrl i�:; L�F��f 1� � J �'� <br /> Vendor Mailir�g Address City State Zip <br /> / _.�, r ,/ / / �( <br /> r�Z'j���'J:�/` 7�I�S��� �I.�'F.,/ �(.`_�j%�%/'Ytic'!`.�Fs,'�.(�>l �L'r.��f�,')iV ��.,f�1��'✓\ <br /> Phone Emai! <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate cl��ck directly <br /> for the installation referenced at the Proper�y Address. By agreeing to receive the rebate <br /> check directly, I agree to the following: <br /> 1. The Backwater Prevention Device rebate a��iount wi31 be deducted from th� iinal <br /> invaice given to the Property Owner for the installation at the Property Addre:;s <br /> referenced above, if the total cost of the installation is greater than the rebate. � <br /> 2. !, the Vendor, am a Washington Stafie Gcensed cor�tractor. <br /> 3. The City of Everett will send a Federai Farr�i 1099 MlSC tn m�, the Vendor, for <br /> the Backwater Prevention Device rebate paymer�ts totaling more ti�an $600 per <br /> calendar year, and wiil repor# the same payments to the I��feri�af Reven�ae: '' <br /> S�NfCP,. ` <br /> � <br /> i <br /> I accept the direct payment of the Backwater Prevention Device rebate from the City <br /> of Everett pending approval of the completed Backwat�r Prevention Device rebate <br /> package by t}�e City of Everett <br /> .� � n� ;f — _,,, <br /> _;' +-C'(.* '' � Z..�.�'���:-� �` � j <br /> �� -� � --------_ �`� ------- <br /> ig115 attlr�e of Corlfractor D��lo <br /> ( � <br /> � <br /> i <br /> � (. <br /> ( <br /> i' <br /> Pn��r� ?_ of 2 <br /> Ri:viseci �3/3/2U14 <br />