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Contractor Section: <br /> �'27tiJ' �C-�va�7., . � F��,hrv� l�f ��o z— '7�z—'�tP', <br /> Vendor Name/Business Name I UBI Numbe• <br /> �A!„l,r-�i PP <br /> State of Washington Contractor License Number: <br /> �G!/ v/Sfa✓c�rZ.L /ILt— �+l-eP�- � 4/20/� <br /> Vendor Mailing Address City State Zip <br /> [,z�— �89�/23 /9�9�1�.+,I�n4Lt� a�n� C�v1�C.Cca..� <br /> �� <br /> Phone Email <br /> I, the Vendor, agree lo receive the Backwater Prevention Device rebate check directly (or the <br /> installation at the above referenced property address. By agreeing to receive the rebale check <br /> �irectly, I agree to the following: <br /> 1. The Backwater Prevention Device rebate amounl will be deducted from Ihe final invoice <br /> given lo Ihe property owner for the instatlation at the property address reFerenced above, if <br /> the total cost of the inslallalion is greater than the rebale. <br /> 2. I, lhe Vendor, am a Washinglon Stale licensed conlractor. <br /> 3. The City of Everell will send a Federal Form 1099 hAISC to me,the Ve�dor, for Backwater <br /> Prevention Device rebate p2yments totaling more lhan $600 per calendar year, and will � <br /> report Ihe same payments to lhc Inlernal Revenue Service. <br /> I accept the payrnent of!he Backwater Prevention Device rebate from the City of Everetl pending <br /> approval of the compleled Dackwater Prevention Device rebate package by lhe City o(Everett <br /> —..��/`����_y' ^``�'�1� G��-ZU -�S <br /> Signature ot Contraclor Date <br />