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i <br /> � <br /> ; <br /> ; <br /> Contractor Section: i <br /> II �1111.L��1�!��r��N� l•x.3 -�/ 3 - v 5 Sl � � <br /> \/endor Name!Business Name I UBI Number � <br /> i <br /> �111.��'L�c��- ------ � <br /> ' State of�Nashington Contractor Licerse Number: I <br /> i � i <br /> S.. <. _�~/4V� NL !��IZY��'�11,ts_._�N2—���Z�%_ ' � <br /> � - <br /> I Vendor Mailing Address City Sta(e Z�p <br /> , � <br /> II (�–�^.����1-�1.� /�7 -------- i I <br /> Phone Email I ' <br /> I i ' <br /> — --------� � <br /> i, the Vendor,agrr.e to rec=ive the Backv�ater Prevention Device robate check directly for the � <br /> �nstallation al lhe above referenced propz�fy address. 8y agreeing to receive the rebate check , <br /> direcJy, I agree to the tollow�ng <br /> 1. The Back�valer Prevemion Device rebate amount will Le deducted from the final invoice <br /> I <br /> given !o the property owner for the installalion at lhe property address referenced above, if i <br /> the tolal cost of lhe instaliation Is greater than the rebate. ' <br /> ' 2 I,the Vendor,am e Washington State hcensed contracbr. � <br /> 3 The City of F.verett n�ill send a Federal Form 1099 MISC to mr., tlie Vendor, for Bar.k�vater j <br /> Prevention Devico rebale payments totaling more than 5600 per ca'endar year, antl will � <br /> report the same payrner�;s;o �he Intemal Revenuo Service ; <br /> r--- - – — -- - --------- -- –� � <br /> `� I accepl ihe payment of the Back�vater�revention Device �ebete from the Cily o(Everett pendinc� j <br /> appro�al ot the compleled Backv�ater Prevenlion Device rebato package by�he City of Eveiett . � <br /> I � <br /> i <br /> I� _ _��1�--- <br /> LSignature of CoMractor --� pate I ` <br /> � <br /> � <br /> � <br />