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contrac�or �ectior�: <br />-�-�-4-�►..--o�--�.-� <br />Vendor Name I Busir�e s�lame 1 UBI Numl�er <br />W.- J <br />State of Washington Contracior License Number: � <br />, , - �. , �----- City State Z�P <br />Vendor Maifing Address <br />����� Emaii <br />I, the Vendor, agree to receive the Backwater ['revention De� �� n� ta�feGehve t e}r eb`ate�check <br />installation at the above referenced proper�Y ad�ress, By g <br />directiy, I agree to the folfowing� <br />1. The Backwater Prevention Device rebate amaunt wi#1 be dedu�ct�e�de °m�f Qe� ��� ab ve, if <br />��V total tcaspofiphe nstallation is greater� than the rebate e�y <br />the <br />2, I, the Vendor, �m a WashingEon State licensed contractor. <br />3. The City of Everett wili senci a FederaV Form 10991VIVSC to mee� Ca endar yeer, and i�,�'�� er <br />Prevention Device rebate payments totaiing more than $600 p <br />report the same payments to the Internal Revenue Service. <br />I accept the payment of the Backwater Prevention Device rebate from the C�tY of Everett pending <br />�PP <br />�aval pf the cotrspleted Bacicwater Prevention Device rebate package by tne City of Everett <br />� � � � �� <br />Date <br />Signature af Contractor <br />