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Contractor Section: <br />VenAor Name! Business IJame / UBI Number <br />.�i.bGl_ PL JI� G i <br />State ot VUashinglon Coniractor License Number: <br />.-S�/G7 7�sY /1vi ,,, ;; .�-,a-rySvr/iG w 9' %�d�'7d <br />Vendor Mailing Address City State Zip <br />3�7 - /.s�� - ---- <br />Phone Email <br />I, the Vendor, agree ro receive the BacMvaler Prevenlion Device mbate check directly for the <br />in�;allalion at lhe ahove reterenced properly address. By agreeing �o receive lhe rebale check <br />directly, I agree lo the following: <br />1. The �ackwaler Prevenlion Device rebate amounl r�111 be deducted from the fnal invoice <br />given to Ihe property owner lor the inslallalion al the property address referenced above, ii <br />the total cost of Ihe ins!allation is greater than the rebale. <br />2. I, ihe Vendor, am a Washington Slale licensed conlractor. <br />3. The City of Everefl will send a Pederel Form 1099 MISC to me, the Vendor, for 9ackwater <br />Prevenlion Uevice rebate paymenls tolaling moie than 5600 per caiendar year, and v;ill <br />report lhe same payments to the IMernal Revenue Sen�ir.e. <br />I accepl tho paymenl of Iho f3ackwater Frevenlion Device rebate from the City o( Everett pending <br />approval of Ihe compteted Backwater Prevenlion Device rebate p�ckage by ihe City of Evereit <br />/�� �__ --- ---- - %3 / .� <br />Signalure oF Contractor Dale <br />