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Contractor Section: <br />r r� �. ccrt�-=� _k�c��(-�i�- �`�c����:1', �-L �.;c>�, ; ,��3 <br />, � �� :� <br />� Vendor Name ![3usiness Name / UBI Number <br />�1 <br />_ /�_1"--��-f�Z�-.�—� � f—, `'�-__-- --- <br />Slale of 1Nashington Coniractor Licer�se Number. <br />�7L�_'•�—�--__�_r�Lit'�._L�_n�._��___E=C�:�-�`' �-%-. �'�'_a�_G'�- <br />Vendor tilailing Address City State Zip <br />aL3c_-A"��%t��-,�t�4�_ ___L'��'ir��.CLr:t.�.�.�_ c',_%tc41�o�?-_C�t�'1 <br />Phone Email <br />I, the Vendor, ar�ree to receive fhe Back�;�ater Prevenlion Device rzbate check direcUy for the <br />installation at the above referenced property address. Ry agreeinc� lo receive 1he rebate check <br />directly. I agree to the following: <br />1. The Back�vater Prevention Uevice rehate amount will be deducled from the fnal invoice <br />given to the property oemer for �he instaltation at the property address referenced above, iF <br />the total cost o` the installa�ion is �realer than Ihe rebale. <br />2 I, the Vendor, am a Washington State licensed contractor. <br />3 The City oi Everett �vil1 send a 1-ederal Form 1099 MISC lo me, the Vendor, for Backwatcr <br />Prevention Device rebate payments totalin� more than �G00 per calendar year, and �vill <br />report the same payrnenls lo lhe INemal Revenue Service. <br />I accept Ihe paymenl of lhe Back�valer Pieventmn Devicc� rc�bate (rom Ihe Cily nf Fverett pending <br />approval o( the compleled 6ackwater Prevention Device rebale package l�y lhe Clly o( Everclt <br />/� � � _ I <br />C� �.-f'�- �G�:r�.--- - ----- �-�1-l�l � - - <br />Signature of Contraclor Oate <br />