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Contractor Section: <br /> 1�-� Pt_c.,�•�i N cR CL.c. Ce o 3 -�zs-- o i �; � <br /> Vendor Name/ Business Name � UBI Number <br /> _ �-�c�v P�cr g C�3 y�_. - - -- — I <br /> State of Washington Contractor License Number: i <br /> Po �x 88� sti���s�� �� . ��zg r _ <br /> Vendor Mailing Address City Slate Zip � <br /> �O�z 4(��4 �n 1 2� `r�,n-{-C.o( Ile•-s� �c4l�ofl �'COfi <br /> Phone Email <br /> I, lhe Vendor, agree to receive the Back�vater Prevention Device rebate check d rec(ly.for lhe <br /> installation at fhe above referer�ced property address. By agreeing to receive the rebale check <br /> directly. I agree to the following: <br /> 1. The Backwater Prevention Device rebate amount will be deducted from ihe final invoice <br /> given to lhe property owner for lhe installation at the property address referenced above, if <br /> lhe total cost of the installation is greater than the rebale. <br /> 2. i, Ihe Vendor, am a N,�ashinglon Slale licensed contractor. <br /> 3. The City of Everelt will send a Federrl Form 1099 MISC to me, the Vendor, (or Backwater <br /> Prevention Device rebale paymenls rotaling more Ihan 5600 per calendar year, and will <br /> report the same payments lo the Inlernal Revenue Service. <br /> I accept the payment of the Back�valer Prevenlion Device rebale from the Cily of Everetl pending <br /> approvai of the completed Backwater Prevention Device rebale package by the City of Everelt <br /> - �- 3 0 - i.S- <br /> Signature of Conlractor Date <br /> � <br />