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Contractor Section: <br /> A�i1�G 1lrM t�y �C/� � �� �Sn <br /> Vendor Name/ Business Name/ UBI Number <br /> �/��1�/�'�G% ----- - <br /> Stale of Washington Contraclor License Number: <br /> 5��� �/J' Ave NE —�GfySL�iie i.,.A 9��70 <br /> VendorMailing Address City State Zip ( <br /> 3�s7�— i S�7 <br /> Phone Email <br /> I, lhe Vendor, agree to receive the Backwater Prevenlion Device rehate check direcliy tor the <br /> ' installation at ihe above referenced property address. By agreeing to receive the rebate check <br /> directly, I agree to ihe foliowing: <br /> 1. The Back���ater Prevention Device rebate amount will be deducled (rom lhe final invoice <br /> given to the property oamer for the installation al lhe property address referenced above, if <br /> the rotal cost oi the installation is greater than the rebale. <br /> 2. I, the Vendor, am a Washington Stale licensed contractor. <br /> 3. The City of Everetl will send a Federal Form 1099 MISC lo me, the Vendor, for Backwaler <br /> Prevention Device rebate payments totaling more than 5600 per calendar year, and will <br /> repoR tha same paymenls to Ihe Inlemal Revenue Service. <br /> I accept the paymenl of the Backwater Prevention Devicc rebate from Ihe City oF Evereri pendmg <br /> appwval of the compleled Backwater Prevention Device rebate package by ihe Ciiy oi Everelt <br /> /�'✓ � ' / <br /> _ �/ 9/ r <br /> Signalure of Conlraclor Dale <br />