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� <br /> Contractor Section: <br /> �r2 � C �.(/c��l� ��uw� Y�IY� �-I.�OZ-7d'Z�� <br /> Vendor Name / Business Name/ UB Number ��� <br /> �-� lP U�a//P/.� <br /> State of Washington Contractor License Number: <br /> �(,�ll ! 'fzt V�.{�t _�f�,-c�T- �4 .`�d`���5 _ . <br /> Vendor Mailing Address City Slate Zip � <br /> _ L�2��18�3-��Z 3 _/'�4�f�����r �C��ntnL-C � <br /> Phone Email �. <br /> I, the Vendor, agree to receive the Backvdater Prevention Device rebate check direclly for the <br /> installation at the above re(erenced property address. E3y agreemg to receive the rebale check <br /> direcUy, I agree to the (ollowing: <br /> 1. The 8ackwater Prevention Device rebate amount will be deducted from the final invoice <br /> given lo the proper(y owner for lhe inslallation al the property address re(erenced above, �f <br /> lhe total cost o(the installation is yreater than ihe rebate. <br /> 2 I, the Vendor, am a Washington Slate licensed contractor. <br /> 3 The Cily ot Everell wdl send a Federal Form 1099 MISC to me, the Vendor, fnr Backwaler <br /> Prevention Device rebate payments totalir g more than �G00 per r,alendar year, and will <br /> report the same payments lo ihe Inlernal F',r.venue Service. <br /> I accept the paymenl o(the Backwaler Prevention Device rebate from Ihe City of Evorett pending <br /> approval oi the completed Backwater Przvention Device rebale p2ckage by the Cily of Everett <br /> _(l'i" , � �`.sCi��S�—! — ��-11-- <br /> Signature of Conlractor Date <br /> i <br />