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Cont�actor Section; <br /> Sewer --- r- �e � �-L C " �t o Z �13`� 78D � <br /> Vendor Name/Business Mame!UBI umber i <br /> I <br /> Sew�Y" -F �- �ll l� vti-� S <br /> Stafe of VJashington Confrattor License Number. <br /> ?c-� ��� �-1�15 L�nn��c�_��U� �'8'0�(a <br /> IVendor Mailino Address_ City State Zip <br /> I �.1� .8�ill. "147 � �iul��.C��e,we.r�ri:�nc�_(ysP� <br /> � <br /> Phone _Email <br /> � <br /> I, the V=ndo:,agiez to.re�eive the Bac'r.v,�ater Preventlon Devlce r2tiate Check dirz���y:fpr the <br /> ms(all�(ion at the abov_ referenmd'ptoFery a�dress. 8y aareeing to receive.the[ebale cfizcK <br /> direcily;l.a9ree.to!h2 following. i <br /> i. i.he Bzck,vater Prevention Devicr rebate amount will ti=_ deducted•from.the LnaLinvoix <br /> given !o.�ie;crop�rty btmer'fo"r.(he iiistallation at ihe propeity addrzss ra(erenced:atioce, if <br /> ?iie total rost of the'inslaliation is groater than tYe zebate. � <br /> 2, I, �he Vendor, em a Washingto� Stale licensed contrac'oc <br /> 3. The City of,Everett tvil(Send a Federal Form 1099 MISC to.m^, thG Vendor,.for Backweter <br /> P.revenlinn�eu�ce rebate paymenis'lotating.more than.SGOD per calendaY'.year"and�i��ill <br /> „ re�qrt tFz same pay,me�ts to the lnlernal.Reyenue 5er.yice. " <br /> I accept the p�yment�(the:Bac6i�atEr Prevenlion Davice rebate from thc Ciry of Ev�rett pentlinQi <br /> aoprov�l of th^coirPiAted �ackv��ter Prevenlion Device rebate package by the City of Everett <br /> .�G:��il,��' ���_�� <br /> Signature of Gontraclor . Dafe <br /> 'i _ _ <br /> • . . . _ -,. :., <br /> � . . <br />