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Contractor Section: <br />r� <br />Vendor Name / Business Nar1�e f UBI Number <br />G U ;� e; <br />M oe� PP :� ss X� ��� ._ <br />Slate of Washington Contractor License Number: <br />17S i S ��l'—' Sf. Sr S,�o�or�� �% �✓IF �r�7 �'i c.i <br />Vendor Mailing Address City State Zip <br />�r�.s�7 <br />Phone <br />Email <br />�, ur,n nl�.,,-,I,,,�N c�,��. <br />I, the Vendor, agree to receive ihe Ba�kwater Preventlon Device rebate check tlirectly for the <br />installation at the above referenced property address. By agreeinr� to reCelve the rebate check <br />Aireclly, I agree lo lhe foltowing: <br />1. The Backurater Preventlon Device rehate amount will be detlucted from ihe final invoice <br />gwen to the property owner (or the Installation at Ihe property address re(erenced above, it <br />the total cost of ihe fnslaliation is greater than iho rebate. <br />Z. I, tlie Vendor, am a Washingion Slate Ilcensed coniractor. <br />3. The City of [verett will send a Federel Form 1099 MISC to me, tiie Vendor, for Backvdaler <br />Preven(ion Device rebate payments totaling more lhan $600 per calendar year, and wili <br />repoit tfie same payments to the Inlernal Revenue Service. <br />I accept Ihe payment of the Bacln�+ater Prevention Device rebale from lhe Ciry of Everelt pendin� <br />npprovel of the completed Bar.lavater P� svention Devlce rebato package by the City of Everell <br />� : �"�� � /J% � �i �'— <br />Slgnalure of Contractor <br />5 -"d � -�s� <br />Dale <br />