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� <br /> ; <br /> Contractor Section: <br /> — _ � 1 <br /> --- � � C � C��, ,�C �.5.'S � <br /> �� �����, .. � �: � �i�� LL c�_—L� � ��t I <br /> t '�frtr'1�-,'=�:��C�.Ji_{-1–'�--�)L�— <br /> ' Vencor Name I Busine�s Name I UDI Number � <br /> �i�i �" F � � K� --- - -- -- - - --- '. <br /> r�a-�L.`_� .`� � = — <br /> � State ot V�'ashinyton Contrador License Number. <br /> . -_ <br /> . . i . • <br /> �2�i.�.�'i4t 1v E'Ci_'1� .l,�- �_._J'_�-a�G� <br /> ,_ �L��i�"!i i`1---Q-L�,-, --�C---� <br /> Vendor ivlai!ing Address City Slale Zio <br /> �ac��;_�tJ�_:�����_ L��:l�rsc<��._.�.�.� �%_��11rT�� ��r1_'1_— <br /> Phone Email <br /> i, the Ven�nr,ag�ee to receive ihe l3ack�vater Prevention Device rebate cher,k directly for Ihe i <br /> ins;allation at 'he aUove referenced properiy address. By agreeiny to receive ihe rebate check , <br /> r�ire�tly. I agree lo the follo�:�ing <br /> The Bar.kv�ater Prevenhon Device rehate amoun�tivi�l be deducted from liie final invoice <br /> given lr, thr prope�ty ovfner fos lhe insf�llalion at Ihe property address referenced above, if . <br /> the����I co5t of the installation is graater than Ihe rehah: <br /> _ I, the Vendor, am a Washinglon State licenser, contrar,loc <br /> i i!���e City ol Everelt�vill send a Pederal Fonn 1099 NiISC to me, thc Vendor, tor Backwalzr 1 <br /> Praven�ion Device robate paymenls tolafing more than 5600 per calendar year, and �adl , <br /> ic�io�i the same paymenls to the Inlernal Revenue Servir,e I <br /> � � menl of the Backw�ter Prevenlion Devico rebate from Ihc City o(Fverett penring ' <br /> iI accept tlic p. y . <br /> approval o!lhe cnmpleted Ciacktivaler Prevention Device rebate pacRac�'1�Y ���e Gily o1 Fver:lt <br /> i <br /> i <br /> � ��� _.- �����<.'_ . - -- - - -�3_�a��� - <br /> --��— Da!e <br /> Signature of Coniractor <br /> – --- <br />