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�onCPacpo� 5ec@iaa5; <br />�'"��C[�/�__ I���nrti �?r�1 <br />Vendor Name! Businzss Na�1%/ U'� Number <br />G �� <br />h1i�ei� P�:� ��- ; � � <br />State of Washington Contractor License Number: <br />17S � 5 �(1'--� yl-. SG S�7ol�or�� S� G/�F �7�7_�9(�' <br />Vendor Mailing Address City Stale Zip <br />�I�.S�%L••U 5'��,u ffcn�"�J h�uC�nr/ii.,,�l�ir��l. co�r <br />Phone Email <br />1, the Vendor, agree to receive the Backv�aler PrevenUon Device rebete cB�cic directly for the <br />installation at the ahove referenced property address. By agreeing to rer,elve the rebate c`+eck <br />directly, I agree to 1he Toilovaing: <br />1. The Backvaeter Pre��ention Device rebate amountwill 6e deducted from the final invoice <br />given to the properiy owner for the installelion at ihe properly address referenced above, if <br />the tolal cost of the inslallation is greater than fhe rebate. <br />2. I, the Vendor, am a Washington Slate Ilcensed conhactor. <br />3. Tha Cily of Everett wiil send a Federel Form 1099 fJIISC to me, the Vendor, for Backwater <br />Prevention Device rebate payments totaling more than �600 per caiendar year, and v�ill <br />report lhe sarne payments to llie Intemal Revenue Servi�e. <br />I accept the paymenl of lhe Bac{nvater Prevention Device rebate trom the City of Everelt pending <br />approvr�l of tho complcled Oackwntnr Pruventlnn Dovice re6ate par,ka�7e by Ihe City of Eve�ett <br />, �✓7 � 1 � %�7Zv=-- 5 —�-�'�� <br />SignaWro of Contractor Date <br />