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�Q�?rar.tae Se�ta�e►: <br /> C �� o"z-`1 �-��3 <br /> �?��"'���t/2/�. ���us�►�iY� , <br /> endor Name/Business Name/U61 Number � <br /> 1�� ,�' G// I°"� <br /> Stale of ashington Contraclor !.icense Number <br /> � �fl C�i ��1i�7'� {rGL1•'i'L� ���I� �.n 44- <br /> Ve�idor Mailing Address City State Zip <br /> ,nz�- �-1-$`�-v�Z�3 �4-�_�l���la�J t.r r � o�, <br /> Phone Email • <br /> I, lhe Vendor, agree to recei�ie lhe Backwa2er Prevention Device rebate check directiy tor the <br /> installation at the above reterenced property address. By agreeing to receive the rebate check <br /> diiecdy, I agree to the following: <br /> 1. The Bachvater Prevention Device rebate amount will be deduc��•! Irom the final invoice <br /> given to the proper4y owner for ihe installaYion at the property address referenced above, if <br /> the total cost o'9he inslallation is grealer lhan the rebate. <br /> 2 I,the Vendor, am a Washington State Iicensed conlractor. <br /> 3. The Ciry of Everett will send a Fede�al rorm 1099 MISC lo me, the Vendor, For Dackwater <br /> Provention Device reb�te payments tol:�ling more 4han$600 per calendar year, and�vill <br /> report the same payments to the Internal Revenue Senii�e. <br /> I accept the payment of the Bar,icwater Prevention Device rebate(rom the Ciiy of Everett pending <br /> approval of the completed Backwater Prevention Device rebate package by the City of Everett <br /> - — -- -�r'"'_� .r-- <br /> t c � �� <br /> Signalure or o� ctor Dale <br />