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Contractor Section: <br />Vendor Name I Busine�s Name I UBI Number <br />A %t ��.Z� �r�.l-K--�- <br />Slate of Washington Coniraclor License Number: <br />Vendor Mailing Address <br />Phono <br />[mail <br />_'�C�..(�'ii'�,�_�__c' • �� - <br />City State Zip <br />I, the Vendor, agree to receive the Eiaokwater Prevenlion Device reb2te check direclly for the <br />installalion at Ihe above re(erenced properly address. By agreeing to receive the rebale check <br />directly, I agree to the following: <br />t. The Backwater Prevantion Device rebate amount will be deducted from the final invoice <br />given to thc property owner for lhe inslallalion at the property address refemnced above, if <br />the lotal cost of Ihe installation is grealer than the rebate. <br />2. 1, the Vendor, am a Washington Stafe licensed contraclor. <br />3. The Cily oi Everelt will send a Federal Porm 1099 MISC to me, Ihe Vendor, (or Backwater <br />prevention Device rehale payments tolaling more ihan $600 per calendar year, and will <br />report the same paymenls to the Intemal Revenue Service. <br />I accepl lhe paymenl ot the Backwaler Prevenlion Device rebate irom lhe Ciry of Everell pending <br />approval of lhe completed Bar.kwaler Prevenlion Device ret�ate package by the Ciry of Everett <br />C�' ������ --- _ _ --�� �.� c� <br />Signature of Contractor <br />Date <br />