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Contractor Section: <br />I N ✓I �'7 1 <br />Vendor Name / Business N�me / UBI Number <br />� L`� ��S � N � <br />,�"I ����.�- Ylr � T O <br />State of VJashington Conlractor License Number: <br />--��5%S �(1��5� )� - <br />Vendor �4ailing Address <br />� � �t.:,(..l } t <br />Cdy <br />State Zip <br />���J , ,' <br />i_ S 7�, C� ��� o i �r.,�(� i-���I�,..�.�2 _ �.,� - <br />Phone Email <br />I, the Vendor, agree to receive the Backwaler Prevention Device rebate check direcUy for the <br />inslallation al lhe above referenced�property address. By agreeing to receive the rebale check <br />directly, I agree to the following: <br />1. The 8ack�aater Prevention Device'rehat� amount will be deducled from the final invoice <br />given to �he property owner for the mstailatico al the property address referenced above, d <br />Ihe lotal cosl of lhe installation is grealer than the rebale. <br />2. I, lhe Vendor, am a Washinglon State hcensed contractor. <br />The Cily o( Everett wiil send a Federal Form tngg MISC lo me„ttie Vendor. (or Backv�aler <br />Prevention Device rebate payments totaling more than 5600 per calendar year, and wiil <br />report the same payments to the Internal Revenue Service. <br />I accept lhe paymenl ol the Back�valer Prevention Oevicr, rebale from the Cily of Everett pending <br />approval of Ihe completed Backwater Preven6on Device rebate E�ackaye by lhe City of Everelt <br />. �f / -F` Z-'`- <br />Signature of Contractor <br />�'�1-/S <br />Date <br />