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i <br /> ; <br /> ; <br /> � <br /> , <br /> ! <br /> Contractor Section: � <br /> � <br /> _�—----- <br /> ------ ---- --._ . .—_ . <br /> i <br /> {� ,- ' • `j�,_� Lt � �C._— r��. C <br /> i�4�;-��1�—��: . 1��_--.1. 1��-_ _— ��- -� 1"-`�`3'.3 � <br /> � Vendor Name I Busine�ame/ UBI Number i <br /> 9_�-F:S 5`� �-�--K -- -_-__-_-- - � <br /> Slate of Washington Coniraclor License Number <br /> ��41 �c i�t--Dp,.-- -��l_�:re��'. ��.7�c���c;� ; <br /> i Vendor Mailing Address Ciry State Zip i <br /> i i <br /> io7[�n=a�-ZG�?tZ�t L'�Ci c�e: . , cJ•�.wD_��.c�.t?'� _ ; <br /> Phone Email <br /> �.�__.— -- — --- — -- —.— - t <br /> I, the Vendor, agree lo receive the[3ackwaler Prevention Device rebate check directty(or lhe ' <br /> In,tallation at the above refere�ced properly address. By agreeing to receive the rebate check <br /> direclly, I agree to Ihe lo�lowing• <br /> L The Backwater Prevention Device rebale amount will be deducted from ihe final invoir.e <br /> given to Ihe propeRy owner for 1he installation at the property address re(erenced above, if <br /> the total cost of�he installalion is greater than lhe rebate , <br /> 2. i, Ihe Vendor, am a Washington State licensed contraclor. � <br /> 3 The City of Evcrett will send a Federal Form 1099 MISC lo me, Ihe Vendor, for Backwater � <br /> I <br /> �revenlion Device rehate payments lotalinc� more�han $600 por calendar year, and will � <br /> report thc same payrnenis!o the Inlemal Revenue 5ervice. � <br /> I acr.ept Ihe paymeid o��hr. Backwater Prevention DevicF>�ebate trnm the C�ry ot Fverell pending � <br /> appraval of the completed Qack�vater Prc:vention Devicr rebate par.ka�r. hy ihe Cily nf Everelt ; <br /> j �, j <br /> <t-�. �-� -"`_" -- - �' �`� - _ _—_ i <br /> � Siynalure ot Contiar,lor Date <br /> i --- — _ - ----- -- ' <br /> � <br /> i <br /> 1 <br />