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�d <br /> Contractor Section� <br /> -- ---- ---- — -- — : <br /> ', �?f�-�-0��;�n"�.��'�v1�—�nU� O(3 �.�S� I� <br /> Vendor Name I Business Name/UBI Number <br /> , --q.P u,o P��u3 L�; -- - - I <br /> � State of Nlashinaton Coniraclor License Number: <br /> ', _��o�_7_1ST_�1�r�----�r mAR�s� wfl �Rz-�� _ <br /> �I Vendor Mailin� Address City Stata Zip <br /> ! �25 38� �SD� �v� �. a Qou-�Pi�mt�r.�c� .Gor�l� <br /> Phone Email j <br /> � — --- —--._�, <br /> I, ihe Vendor, agree lo receive the Backvdater Preven;ion Device rebale check direclly(or the <br /> inslallation at the above referenced property address. By agreeing to receive the rebate check <br /> directly, I agree lo the follon�ing <br /> 1. The Backwater Prevention Device rebate amounl �^aill b�deducted from the final invoice <br /> given b lhe property o�vner for the insfallation al the property address referenced above, if <br /> the total cost o(lhe inslallalion is grn_ater than the rcbate. <br /> 2. I, lhe Vendor, am a Washington Slale licensed contractor. � � <br /> 3. The City of Everell will send a Federal Form 1099 MISC lo me, the Vendor, for Backwa�er <br /> Prevenlion Device rebate payments totaling more than 5600 per calendar year, anJ will I <br /> report lhe same payments to lhe Intemal Revenue Service. 1 <br /> � <br /> ! I accept tlie paymenl of Uie Backwaler Prevention Device rebale (rom lhe Cily of Everetl pending l I <br /> approval of the compleled Backwaler Prevenlion Device rebale package by the City of Everett <br /> / <br /> � � <br /> Siynature of Contr� c �r <br /> � Dalc <br /> l __ ... _ ---- —-- ------ <br />