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Contractor Section: <br /> � -- — --- -. . ------ --- --i <br /> ��Pol/G /wr,ji;.�_(�i3 ci/3 oS�1 <br /> Vendor Name I Business Name/ UBI Number <br /> �l'�.—liGGp�.�3�Y— - — � <br /> State oi Washington Contraclor license Number � <br /> i <br /> � S�/G] 7/S+/fu���i .✓�a�Sv!//G �1/.a' r,S��/ I <br /> Vendor Mailing Address Gily Siate Zip <br /> �i �f37" �-��_ � � <br /> IPhone Email <br /> I <br /> — —-- -- ' <br /> I, the Vendor, agree to receive the Backwaler Prevention Device rebale check directly for the <br /> mstallation at lhe above referenced property address. By agreeing to receive the rebate check <br /> direclly, I agree lo the follo�ving: <br /> 1. The Backtivaler Prevenlion �evice rebate amounl will be deducted (rom Ihe final mvoice <br /> given ro lhe property ovmer for the installation at thc property address ir.ferenr.ed above, if <br /> the total cost of the inslallation is greater lhan lhe rebate <br /> 2. I, tt�e Vendor, am a 1Nashington State licensed contraclor. <br /> 3. The City of Everett will send a Federal Form 1099 MISC to rt;e, Uie Vc��dor, for Back�ti-ater <br /> Prevention Device rebate payments tolahng more than 5600 per calendar year, and will <br /> report the same payments to the Inlernal Revenue Service. <br /> r ____ __ _____ _ ___ _______ ___� <br /> � I accept the payment ui Ihe 8ackwaler Prevention Device rebate from the City oI Everetl pending <br /> approval of the compleled Back�vater Prevention Device rebate package by the City of Everett <br /> i <br /> - _ 3 i �r <br /> Signature of Contractor Dale <br /> � <br />