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r " <br /> I Contractor Section: <br /> �Y/il./.U��I,s,M�L.✓v (�� —�/ 3 — ciS� <br /> Vendor Name/Business Name!UBI Number <br /> �tfL_G 1�'` S7o� L; <br /> State of Washington C��ntractor License Number: <br /> .S�G� 7/sr/1V� NL MAIs .51IL j; Lt//j 7.Cf�7�J <br /> Vendor Mailing Atldress Ciry Stato Zip <br /> "�r.2L��1.�G7 - - <br /> Phono ' Email <br /> I, the Vendor, agree ro recoive the 8ackwater Provenlion Oevice rebate check dire�lly(or Ihe <br /> inslallation al the above referenced properiy eddress. By agreeing to receive ihe rebate check <br /> dire,0y, I agree to the fullowing: <br /> 1. The Backv�ater Prevantion Dovice rebate amount will be deducted irom ihe final involce <br /> given fo Ihe property owner for the installation at the property address referenced above, If <br /> the total cost of Ihe installatlon Is yreater than the rebate. <br /> 2. I, the Vendor, am a Washington State liconsed contractor. <br /> 3. The Ciry of Evoroit�vill send a Federal Form 1099 MISC to me,the Vendor, for Backwater <br /> Prevenlion Device rohale paymonts tr,lalinc� more than S600 per calendar year, and e�ill <br /> report Ihe same paymenis to the Inlernal Revenuo Service. <br /> I ar.cept the payment of lho Bar,kv+ater Prevonllon Device rebalo from thr.Cily of Evc�rc�U pending <br /> approval of the compleled Back�valor Prevention Uevice rebato package by the Ciry of Everell <br /> � _ — -�-�LS IT -- <br /> Signalure of Contraclor ��. Date <br />