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Contractor Section: <br />�'o//o j'iun �� /;�o_� � / � a� S1 <br />Vendor Name / Business Name / UBI Number <br />��Lc:..�L_����y - <br />State of VJashington Contractor License Number. <br />_S�� %is�A✓c� N,� ,�.r u.� i s d r; �� w_� __,S��i'� �� <br />Vendor Mailing F�ddress City State Zip <br />�57� �So% --- ------.. <br />Phone Email <br />I, the Vendor, agree to receive the Back�vater Prevention Device rebate check directty for the <br />installation at the above referenced property address. By agreeing to receive the rebate check <br />directly, I agree ta the tollowing: <br />1. 7he Baclna�ater Prevention Device rebate amount will be deducled from the final invoice <br />given to the propeAy owner for the installation al the property address referenced above, if <br />the lotal cost of the installalion is greater than the rebate. <br />2. 1, the Vendor, am a\Nashington State licensed contraclor. <br />3. The City of Everelt will send a Pede�al Form 1099 MISC to me, the Vendor, for Backwater <br />Prevention Device rebale paymenls �otaling more than 5600 per calendar year, and wiil <br />report the same paymenls to the Internal Revenue Service. <br />I accepl the payment oF the Backwaler Prevention Device rebate trom lhe Ciry of [veretl pending <br />approval ot Ihe completed Baclnvaler Prevention Device rebate package by the City of Everett <br />SignaWre of Contraclor Dale <br />