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i <br /> , <br /> ; <br /> � <br /> � <br /> Contractor Section: ; <br /> � <br /> i � <br /> I �1.L� /�GLt M j L n/�% (�.i -tiJ � - ti S Sl i <br /> Vendor Name!Business Name/U81 Number � <br /> I �1�L1.��'G�i L; I i <br /> IState of Washington Contraclor Ucense Number. ' � <br /> .S'�G7 ��j r/4✓= /✓L �iy���s:/l/� �ff�,7fJ I � <br /> Vendor Mailin�Address City Stato Zip I ' <br /> � C�.�SJ ��� .����7 _ <br /> iPhono Email — � ; <br /> I • <br /> i, the Vendor, agree to recelve Ihe Backwater Prevention Deviee rebate check direclly for the , <br /> installation et tho above refsrenr.ed property address. By agreeing to receive the rebata chack <br /> direcUy.I agree to the foltowing <br /> 1. The 8ackwater Provention Device rebate amounl v:ill be deducted(rom the flna!mvoice <br /> given to the property owner`or the installation al the property address referenced ahove, if <br /> the total cost of the i�stalla8on is greater than the rebate. <br /> 2 I,the Vendor, am a Washington State licensed contraclor. � <br /> 3. Tho Cily of[verett villl sond a Federal Form 1099 MISC to me,tho Vendor,for Backwater <br /> Preventlon pevice rebato payments totaling moro ihan S60D per ca�endar year, and will ' <br /> report the same paymenis to tho Intemal Revonuo Service. <br /> + ^i <br /> II accept the payment of the Backwaler Prevention Device rabale trom the Cily of Everelt pendin� i � <br /> , approval of the completed Back�vater Preven!ion Davice rebate packege by the Citq of Everell I <br /> I <br /> I • <br /> � _ �/.3G/i,f ! <br /> Signalure of Contractor —�. Date � <br /> i <br />