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i <br /> , <br /> i <br /> � <br /> i <br /> Contractor Section: <br /> ���� ,/ / �) . / / � <br /> V�.��.M ��(. iVU' (�'J J '� UI � � �JS�� i <br /> Vendor Nam2/ Business Name ! UBI Number ; <br /> i <br /> � ��ri G /-�%_ S�Gj L-_i — � <br /> S�ate of V�ashington Contractor Llcense Number. <br /> S�/li7 7/'rf�i/o Ni=_. /i9/�12Y5 'v'�!_�l�i-1N�__' -' li <br /> Vendor Mailing Address City State Zip ; <br /> � "�� �-��Z�.�O 7 <br /> ,' Pnone Email <br /> I � ; <br /> I, the Vendor, egrze to rece:ve the Backt^rater Prevention Davice rebate check directly for ihe ; <br /> instaliation at the abova reTerenc2d prop�ry address. By aoreeing to receive the rebate ch�ck i <br /> airectry, 1 agree ro the foliowing: ! <br /> 1. The Back�vater Prevention Device rebate amount�a�ill be oeducted frem the final invoica <br /> given to tha property o�vner for ihe installation at the property address referenced above, i( <br /> the totai cost oi the instailatlon is greater than the rebale. ! <br /> 2. I, the Vendor, am a VJa>hington State licensed contractoc � <br /> 3. The City of Everett vrill send a Federal Form 1099 tJ�ISC to me, the Vendor, for Backwa2er i <br /> Prevention Device rebate payments tolaling more than ��G00 per calendar year, and tvill ; <br /> repoR the same uayments to the Internal Revenue Service. <br /> � <br /> � I accept fne payment of the Back�vater Prevention C'Avice rebate irom the City of Everelt pendiny <br /> approval of the completed Back�vater Prevention De�ice re6ate package by ihe City of Everetl <br /> � ' � <br /> � S , <br /> < i <br /> �J _ <br /> Signature of Contractor . Date <br /> � <br /> I <br /> � <br />