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Contractor Section: <br /> �--- ----- <br /> �,�n� �7�. �p/`ry,b,in� ll c /o� - 'r�z- 7J' � <br /> Vendor Name I Dusiness Name I UBI Nwnber <br /> ��%/�o-o/r /� -- -- — <br /> State of Washington Contractor[_icense Number: <br /> �lp(/ I//.J�i/lLN4cC �'!l� i��f'�— (� ��•e� <br /> Vendor Mailing Address Cily State Zip <br /> ,clz1= y�9- o�z3 i9t4- p/on-�bn-�slcc a�7� �rml. l <br /> Phone Email <br /> I,the Vendor, agree to receive the Backwater Prevention Device rebate check directly tor lhe <br /> instailation at the above referenced propeRy address. By agreeing to receive the rebale check <br /> direclly, I agree to the following: <br /> 1. The Backvdaler Prevenlion�evice rebate amount�vill be deducted from the(inal invoice <br /> given lo lhe property owner for lhe inslallation at the property address referenced above, if <br /> lhe lotal cosl of the installation is greater lhan the rebate. <br /> 2. I,lhe Vendor, am a Washington Stale licensed contractor. <br /> 3. The City of Everelt will send a Federal Form 1099 MISC to me, the Vendor,for Dar,kwater <br /> Prevenlion Device rebale payments�olaling more than 5604 per calendar year, and will <br /> report Ihe same paymenls lo Ihe Intemal Revenue Service. <br /> 1 accept lhe payment of lhe Backwaler Prevention Device rebate irom the City of Everetl pending <br /> approval of Ihe completed Backwater Prevenlion Device rebate package by the Cily oi Everett <br /> l' ��i , -- ��—�5�—/S <br /> SignaWre of Conlractor Date <br />