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Contractor Section: <br /> � � � _ ? _ r — _ <br /> 1- �_l,� �L_�.i'i�? i'+11' ��_ L:�.'_ � ( l _. i : l� <br /> Vendor Name I Qusiness Nrme I UE31 Number <br /> �Y��.�J�'�-�1,� )? �T -- - - - --- — � <br /> Sla�e oi VYashmgton Contractor License Nwnber <br /> . _'1 `7/�� �'�'^ Ij�_ �� ��J_'-� (11!i�_�j,'�.'_II __ ��_�_ _ ( ��r+ J � ' <br /> , Vendor IJlaihng Address Gty State Zip I <br /> � y;i�� �� � ����,7 .u�`�� �'-�� r�1NGuL' L�:��1�31� �1�� <br /> -- N -- ��--_ �i <br /> Phone Ema�l ! <br /> ' - ---- — � <br /> I. Lie Vendur, ayree t� ie�-ave Ihe Dack�vater Prevenho� Device rebate check directly lor Ihe � <br /> uislalla6on at R�e abnve iPiPranced property adAress By agrer.iny to receive the robate che�k <br /> dr�r;�.liy, I agree to thr� (nllowmq <br /> � ThN 3�ckwatFr PrevenUon Device reba�e ;u•i0unt will be dedur��� frorn Ihe fmat �m�u ce <br /> q�vr�, �o the p�operty ovmer lor ihe inslallalion a� Ihe prup��rty ,iddn�s5 mf�v�ncr�� nhm-o. d <br /> t���• b, I cosl of Ihe installalion is greater than ihe rebate <br /> 1 I t��e Vendur, am a INash�ngton Slate hcensed conUador <br /> 1 I h�� (,�ly ul Fverel� �•+dl send a Federal form 1099 R115C t�, nic, ihi: Vend,.��. I��r g�r,,F�v,�tei <br /> 1'irvenhon DPvicP rebate paymenis tntahng mnre�han Sf>00 {��•r c.ii�;nd,u S•ear, and �:-di <br /> r��r�nrt Gie sarne paymenls lo the Intern�l Rcvenue Service <br /> I ;ic�.epl �he payment ol th� [�ark�vat��r Prevnnhon D��wce rrbtde himi Ihe Gity uf Evuretl pendmq �, <br /> ,qµnuval ul�he complelud B,ickv:nir,r Prevnnbon n�vire rrb:d�� ��,�ckage by Ihe Cd��of Everul� � <br /> i' ! / <br /> . <br /> , r , <br /> , �i`%I ' ! '� <br /> . <br /> , , ; <br /> ' ,,., f(�! ,�jl'l��'`�,l .- - __ _ _. _ Jf��� ��� _ <br /> Siyna�ure ol Cont�ac bl r Datr � <br />