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i <br /> � <br /> Contractor Section: i <br /> /�t''l�/.L.D �i;�.rMi,�nJv (�.'> •-o/ > -cv5'Sf ! <br /> Vendor Name/Business Name! UBI Number � <br /> � l'ClL��G S�G� C'; i <br /> , <br /> Siate of Washington Contrac;or License Number. � <br /> /� i <br /> .S`�G7 �7/'��'i/� A/�, M/11iYSiJillj: lN/� 7,��iCJ � <br /> Vendor lviailing Address City State Zip i <br /> �:s) �rs7 •-!�a� ; <br /> � <br /> Phone ' Email <br /> i <br /> i <br /> I, ihe Vendor,agree to receive the Backv.ater Prevention Devic� rebate check directiy for the ' <br /> installation al the abov2 referer,ced proper�y eddress. By aareeing to receive lhe rebate check � <br /> direclly, I agree to the follo�virg: ; <br /> 1, The Back�vater Prevzntion Device rebate amount�vill be deducted from the final invoice i <br /> given to the property oeaner for the installation at the property address referenced above,if <br /> the,otal cost or the Installation Is grealer than the rebate. � <br /> 2, I, the Vendor, am a Washington State licenszd contractor. � <br /> 3. The Cily of Everett�vill send a Federal Form 1099 h41SC to me,the Vendor, for Back�valer � <br /> Prevention Device rebate payments totaling more than S60D p.r calend2r year, and�vill <br /> report the same paymenls lo the Inlernal Revenue Service. <br /> � <br /> i <br /> ( accept the payment of the Baekwater PrevenUon Device rebate from the City oi Everett pendiny � <br /> approval of the compleled Backwaler Preveniion Device rebate package by ihe Ciiy of Everett I <br /> I <br /> f <br /> �� � �^ � � � <br /> — I <br /> Signature of Contractor ,. Date <br /> j <br /> E <br /> :' <br /> i <br /> 1 <br />