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i <br /> 1 <br /> 477- Backwater Prevention Device <br /> Rebate Program g m 3 <br /> Vendor Section (please print); <br /> CAImp'bat','S 'RLtia J J t�v 6% c t u q0iLf <br /> Vendor Name/Business Name/ UBI Number <br /> CAii-v PgPz awl mi <br /> St4t.0 of Was ngton Contractor License Number: <br /> 0t 6. i W/ 1 a ..- L <br /> Vendor Mailing Address City State Zip <br /> 6 r <br /> � � i_ ' i `etc V t C.0 6 C V fr M i y' brit-, <br /> Phone Email J <br /> i <br /> i <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 to receive the rebate <br /> check directly, I agree to the following: <br /> i <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final <br /> invoice given to the Property Owner for the installation at the Property Address <br /> referenced above, if the total cost of the installation is greater than the rebate. <br /> 2. I, the Vendor, am a Washington State licensed contractor. <br /> 3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for <br /> the Backwater 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 /> 1 <br /> I accept the direct payment of the Backwater Prevention Device rebate from the City <br /> of Everett pending approval of the completed Backwater Prevention Device rebate <br /> package by the ' of Everett <br /> _ .. //ith --"? ic.--- xi <br /> Signature,-.f Contractor Date <br /> ORIPI <br /> i <br /> Revised 9/3/2014 Page 2 of <br /> 1 <br />