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Contractor Section: <br />Vendor Name ! Business Name / UBI Number <br />�� _G�7Q- �.�/:v�-D��l� <br />� State a( ashington Contractor Cicense Number <br />—b'��_�1f Li: �-cl/�(__.�"� —.��=�,G� L.1�-4- ��'�-� j— � <br />Vendor fvtailing Address C�ly State Zip � <br />� �189- o/z : <br />I Phone <br />,4-t� /��,�� bri� <br />Email � <br />CL.0 ��I��.�,1(-�_�,, <br />I, lhe Vendor, agree to receive the Back�vater Prevenlion Device rebale check directly for the <br />installalion at the above referenced property address. By agreeing to receive the rebate check <br />direclly, I agree to Ihe follo�.ving: <br />1. The Backwaler Prevention Device iebate amount e�ill be deducled from the final invoice <br />given to the property ovmer for thc roslallation at the property address referenced above, if <br />the lotai cost of the inslallation is grealer lhan the rebale. <br />2. I, lhe Vendor, am a\4�ashington State licensed coMracror. <br />3. The Cily o( Everelt vrill send a Federal Form �099 h41SC to me, the Vendor, for t3ackwater <br />Prevention Device rebate payments totaling more lhan 5600 per calendar year, and v�ill <br />report the same paymenls lo Ihe Internal Revenue Servlce <br />I accept the payment ot the Backwater Prevenlion Device rebate from lhe City of Everett pending <br />approval o( Ihe compteted Back�vater Prevention Device rebate packaye by ihe City of Everett <br />% � , ��' j �`_ /- /_ � d- � j= <br />� <br />Signature of Coniractor Date <br />