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Contractor :Section: <br /> �S '✓1.C,.1� �r...j� � p��Vr+ yllYl �CL �ai- 7i2 -�83 <br /> Vendor Name!Bu:>iness Name/UBI Number <br /> i � Pi�,�.� h,�,-9 — f9� �',���o�i��J <br /> State of Washington Contractor License Number. <br /> ,P�!ll v�,S�'a r2r�R t�'LF ,r--ecGu' r,wt 9�'z os-' <br /> Vendor Mailing Address City Stale Zip <br /> �z � � 9 9 —oiz'� �- Pl�_�-,hi� CLL '�'/-2/�'C'rnr�i/, <br /> Phone Email <br /> I, the Vendor, agree to receive lhe Backwatei Prevention Device rebale check directiy for lhe <br /> installation at the above referenced property address. By agreeing to receive the rebate check <br /> directly, I agree lo lhe following: <br /> 1. The Backwaler Prevention Device n:bate amounl�vill be deducled from the final invoice <br /> given lo the property owner tor the i�stallation at the property address referenced above, if <br /> the total cosl of the inslallalion is greater lhan the rebale. <br /> 2. I, the Vendor, am a Washington S�ate licensed contractor. <br /> 3. The City of Everett will send a Federal Form 1U99 MISC to me, the Vendor, for Backwater � <br /> Prevention Device rebate payments totaling more than 3600 per calendar year, and will <br /> report the same payments to the Intemal Revenue Service. I <br /> I accept the payment of Ihe Backwaler Prevention Device rebale(rom the City of Everett pending <br /> approv�i of the completed Backwater Prevenlion Device rebate package by the City oi Everett <br /> .l.J.o� /��������5� 3/d���S� <br /> Signature of Coniracbr Date <br />