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Contractor Section: <br />Vendor Name I BusineSs Name / UBI Number <br />���'l.r ''�_���-`�-�-�- K�- <br />State of Washington Contraclor License Number. <br />Vendor tvlailing Address <br />City Slate Z�P <br />�"a�-1Q�',.�Si� �_'L'Xiil'�CeE:_�.a.�. c,�%'��_1JS.i� =�'.—r'h! <br />Phone Email <br />I, the Vendor, ag�ee to receive the Backv�ater Prevenlion Device rebate check direclly for lhe <br />inslallation at the above referenced property address. By agreeing to receive the reba,e check <br />direclly, I agreo to thz follo�l�ing' <br />tl <br />2. <br />3. <br />The Backwaler Prevenlion Device rebate amount vrll be deducted irom the final invoice <br />given to lhe property ewner for Ihe installation at the property address refcrenced above, if <br />tne tolal cost of thc instaliation is �reater than the rebat2. <br />I, the Vendor, am a Washington Slate licensed contraclor. <br />Tlie Ci�y o� [verett �vill send a Fedcral Form 1099 MISC to me, Ihe Vendor, for Backwater <br />Prevention Device rebate payments totaling more than 5600 per calendar year, and vdill <br />report ihe same payments lo the Intemal Re��enue Service. <br />� <br />I accep[ the paymenl of the Backavaler Provention Device rebate from Ihe City oF Everett pendinc� <br />approval of the comple�ed Bacfavater Prevention Device rebate package by lhe City of Everell <br />� � ��� _ � � a�3 lJ _ <br />--�� -- <br />Signature o� Contractor Dale <br />9 <br />u <br />Y <br />