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I <br /> I <br /> � <br /> II <br /> Contractor Section: <br /> �U�t�u�t1-Y-�`� ��-�����c� i LL(� �acy'� ;3�4�3 <br /> Vendor Name I B�sine s Name/ UBI Number <br /> �L.��Z-`�.`-�� �1-1�� <br /> State of Washingion Contractor License Number: <br /> � �.�_[a L-c.►l�.i� t� o�. E�_�s�1-f_�,�-�__�c'�'�3 <br /> Vendor Mailing Address City State Zip <br /> ��I�,�n ga C��y�;�i_c�v? . <<�(r�-(�cxLorl2_ <br /> Phone Email <br /> I, :ne Vendor, agree to receive the Backvaater Prevention C„vice rebate check directly for the <br /> insta:ation at the ahove referenced property address. By agreeing fo receive the rebate check <br /> direcUy, I agree to the follo�:�ing• <br /> 1. The Backwaler Prevenlion Device rebate amount will be deducted from lhe final invoice <br /> given to the property owner tor the installation at the property address referenced above, if <br /> the total cost of ihe installation is grcater than the rehate. <br /> 2. I, the Vendor, am a Washington State licensed contractor. <br /> 3. The Cily of Fverett�vill send a Federal Form 1099 tu11SC to mc, the Vendor, (or Backwater <br /> Prevention Device rebate payments totaling more than 5600 per calendar year, and will <br /> repoA the same payments to ihe Internal Reverue Service. <br /> I accept the payment of the Bar.kwaler Prevenlion Device rebale from the Cily of Everett pending <br /> approval of Ihe completed Backwater P�eventinn Device rebate package by lhe Ciry of Everetl <br /> �� -�- � ��:5-� - �f� <br /> Signature of Contractor Dale <br />