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Contractor�ection: <br /> , <br /> ���.f�`�CC�-_ �' ' �_.�-i�'_�-`,�r>/`.�.LL- �r�. " �-�'.� <br /> Vendor Name! Business Name/UBI Number <br /> f�Mi=i;�S� � I Ki_ <br /> State of Washington Contraclor License Number: <br /> al�(Y� �-�r�,_,�� `� EI .0 f"4.!�t �'j�';3 <br /> Vendor Mailing Address City �tate Zip <br /> ��i�dcz-���-,--���'� ��� - � C�/�r?'r'!'icc���CL�G' • •.���C��i7� <br /> Phone Email <br /> � _-. �-.--.� <br /> I, the Vendor,agree to receive the Back�vater Prevenlion Device rehate check direclly for Ihe <br /> installation al the above referenced property address. By agreeino to receive fhe rebate check <br /> directly,I agree to the following: <br /> 1. The Baclnvaler Prevention Device rebale amount will 6e deducted from the final invoice <br /> given in the property owner for Ihe instailalion al the property address reterenced above, i( <br /> the folat cost of the inslallatiodis g�eater fhan the rebate. <br /> 2. I,thc Vendor, am a Washi�gton Stale licer.sed conlracto�. <br /> 3. Th2 City of Eve�elt will send a Federal Fomi iD99 MISC lo me,the Vendor,for Oackwater <br /> Prevention Device rebatr. p�ymr.n�s totaling more than$600 per calendar year, and will <br /> report the same paymenis to the Inlemai Revenue Sn�vice. <br /> I accepi the payment o(the Eiackwater Prevention Uevice rebate Irom the Ciry of Everett pending <br /> approval of the completed�ackwater Prevemion Device rebate package by the Cily of Everell <br /> �� -.z: . ��> >�._ �a�-��� <br /> Signature of Contractor Date <br />