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L <br /> Contractor Section: <br /> (,�or 7lZ-7 <br /> ��s �s��w�_���b� z�c -- <br /> Vendor Name 1 Business Name I UBI Number <br /> �AI�I �_ oi�Pn -- ---- <br /> State of Washingfon Contractor License Number. <br /> __�,p Gl ILLS�.��ei�na�.19� �i..e� � �''d''�._.�' <br /> Vendor Mailing Address City Stale Zip <br /> �l�- � �18�-6IZ3 �- ����,� hr '�q (�L B-�1@C'�-C <br /> Phone Email <br /> I <br /> i � <br /> �— <br /> I, lhe Vendor, agree to receive the Backwaler Prevention De�nce rebale check directly for ihe <br /> installation at the above referenced property address. By agreeing to receive lhe rebate check <br /> di�eclly, I agree to the follovring <br /> 1 The Backwater Prevention Device rebate amount�vill'be deducled•(rom the final invoice <br /> given to the property owner for the installation at the property address referenced above, if <br /> lhe total cost of the installation is greater than the rebale. <br /> 2. I, the Vendor, am a Washington Statedicensed contractor. <br /> 3. The City of Everetl��ill send aFederal Form 1099 MISC to me, the Vendor, for Backtvater <br /> f'revention Device rebate payments tolaling more than �600 per c4lendar year, and v�ill <br /> report the same paymenls to the Intemal.Revenue Service. <br /> I accep( Ihe payment of the Backwaler Prevenlion Device rebate from lhe Ciry of Everett pending <br /> approval of the completed Backvdaler Prevention Device rebate package by lhe Citybf Everett <br /> i <br /> 1 ��� �,--/d'/s <br /> � -- - <br /> Signawre of Centractor Date <br />