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r,� <br /> Contractor Section: <br /> �v2- _1 Z'"713 <br /> ���S �U1��� l�C�-`_t,�- , i�'tR-�Pl W✓��o iv_�� Ll-� --- <br /> Vendor Name / Business Name/ UBI N mher <br /> ,s4�, .�lu �///�[� <br /> State of Washington Contractor License Number. <br /> (o �� (/!S-/-�-raw� p'� -�nT w�-- 9�'1�� <br /> Vendor Mailing Address City State Zip <br /> ,Cl�f- U 8 9-0/Z� �y.�J �v,�l�r �c����7�'�s-`�le�-- <br /> Phone Emaii <br /> I, the Vendor, agree to receive the Backwaler Prevention Device rebate check direclly for the <br /> installation at the above referenced property address. By agreeing fo receive the rebale check <br /> direcily, I agree to the following: <br /> L The Bar.kwater Prevenlion Device rebalr. amount will be deducted from the (inal invoice <br /> given to the property owner for Ihe installation at lhe property address referenced above, if <br /> the btal cosl of the installation is c�realer than the rebale. <br /> 2 I, the Vendor, am a Washington State licensed conlraclor. <br /> 3. The Ciry of Everett will send a Federal Form 1099 MISC to me, the Vendor, for Backwaler <br /> Prevention Device rebate paymenls totaling more than 5600 per calendar year, and �vill <br /> report ihe samc payments to ihe Intcrna� Revenue Service. <br /> I accept lhe payment of Ihe Eiar,kwater Prevenlion Device rebate from ihe Cily of[verett pending <br /> approval of lhe r,ompleted Backwater Prevenlion Device rebate packape by the City of Everell <br /> - ��I— — --- ---- -- – __ CO–Is–�S� <br /> re-of Conlractor Date <br />