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� <br /> � <br /> , <br /> , <br /> ; <br /> � <br /> ContracQor 5ec4ion: ; <br /> � <br /> � <br /> ����� I�I��h �����c ' L �� ,.: C:Sl�I �-��1:� t <br /> Vendor Name!Business Na e!UBI Number ' S <br /> M �en 1'� � S�k �i�� � <br /> State of Washington Contractor License Number: i <br /> 4 <br /> 1 75 15 �tl `—'� Sf. SE S���f���,� �l� w"/4 �S'7_`) 0 i <br /> Vendor Mailing Address City State Zip j <br /> �i � �� 7C U S'�C•C: i�rzn� CJ n� uC� nl�.�l„r��j coch � <br /> ; <br /> Phone Email <br /> I <br /> i <br /> I, the Vendor,agree to receive the Backv+ater Prevention Device rebale check dlrectly tor ths j <br /> installation at the above referenced properiy address. By agreeing te receive the rebate check � <br /> dfrectly, I agree to the folloveing: j <br /> 1. The Backviater Prevention Device rebate amount wiil be deducted from the finai Invoice i <br /> given to the propedy owna for the installation at the property address referenced above, if i <br /> the total cost of the Installation is greater than the rebate. y <br /> 2. I, Uie Vendor, am a Washington State Ilcensed contractor. � <br /> 3. The Clty of Everelt wiil send a Federal Form 1099 MISC to me,lhe Vendor, for Beckwater y <br /> Prevention Device rebate paymenls lotaling more than 5600 per calendar year, and will { <br /> report the same Fayments to the internal Revenue Service. ! <br /> I <br /> -- ' <br /> — � <br /> I accept the payment of the Back�vater Prevenllon Device rebate from the Ciry of E��erett pending : <br /> opproval of thc complolod Bac4avater Provontion Dc�vica robate packago by ihe City of Everett � <br /> I <br /> I �J f �J' %yl2c.�— S -1 �—i �� i <br /> ,/2,i✓ i ' <br /> Signature ot Conlractor Date <br /> i <br /> � <br /> ' . I <br /> � <br /> ' � 1 <br /> . i <br /> ' ! <br /> i <br /> � <br />