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Contractor Section: <br /> ��11c� P�w�n�� C�3 ri� G S� <br /> Vendor Name I Business Name/UBI Number <br /> /���LG/'�L�3LT -- <br /> State of Washinglon Contractor License Number <br /> s�o7 7/'s�A�e��� r+a/�/SV%/�c v.4� 1�s�7r/ <br /> Vendor Wlailing Address City State Zip <br /> _3��5� -_ � <br /> Phone Email � <br /> I, Ihe Vendor, agree to receive the Backwater Prevention Device rebate check direc!ly for the <br /> inslallalion at theabove referenced property address. By agreeing to receive the rebate check <br /> directly, I agree to the following: <br /> 1. The Backwater Prevention Device rebale amount wiil be deducled from the 6nal invoice <br /> given to the.property owner for the installalion at Ihe property address referenced above, i( <br /> the total cost of the inslallation is greater than the rebate. <br /> 2. I, the Vendor, am a Washington State licensed contraclor. <br /> 3 The City oi Everelt will send a Federaf Form 1099 MISC to me, the Vendor, for Backwater <br /> Prevention Device rebale payments totaling more than 5600 per calendar year, and will <br /> report the same payments to the Intemal Revenue Service. <br /> I accept lhe payment of ihe Back�vater Prevention Device rebate from Ihe City o(Everell pendiny <br /> appruval of lhe completed Backwater Prevention Device rebate package by the City of Everelt <br /> ���i' _ <br /> 3/9�i.� <br /> SignaWre of Contractor Date <br />