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• r� � : <br />� <br />Vendor iVame ! Business Name ! <br />Number <br />State ofi Washingtan Cantractor License I�umber: <br />� � ��.�,�� �, _ � �'_,�{~.. ��- <br />V�ndor Mailing Addr�ss City State Zip <br />�. ,� �._�~.� �a��-� <br />Phone <br />Emai! <br />� <br />I, the Vendor, agr�� to receive the Backwater Prevention Device relaate check directly for#he <br />installaiion a# the above referenced praperty address. By agreeing ia receive the rebate check <br />directiy, I agree to the fol[�iwing: <br />1. The Backwater Prevenfion Device rebate amount will be deducted from the final invoice <br />given ta the property owner for t�e installation �t the property �ddress referenced abov�, if <br />the total cost ofi the installatian is greater than tha rebate. <br />2. I, the V�ndor, am a Washington State dicensed contrac#or, <br />3. The City of Evere#t will send a Federal Form 9Q99 MiSC to me, the Vendor, for �ackwater <br />F'reventian Qevice rebate payrnents totaling more than $600 per calendar year, and will <br />report the same payments to the Intern�l Revenue Service. <br />I accept the payment of the �ackwater Prevenfion Device rek�ate fram the Ci#y crfi Everett penciing <br />approvai o�F the completi��i Backwater Prevent't�an Ci�vice re�iate paek�ge t�y the Ci#y ofi �ver�tt <br />�� <br />Signature of Gontractor <br />������� � <br />Date <br />