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i <br /> I <br /> I <br /> i <br /> i;ontractor Section: � <br /> _ <br /> ; <br /> 1 <br /> /�Y,-�LL.C>_1lld��Nv' (�>' —�l � - �5� � <br /> Vendor Name!Business Name I UBI Number � <br /> i <br /> � �tL'LL ' �' � � <br /> � Slate of Washington Contraclor License Number: ; <br /> S`c� 7/5~/}v� Nt_ M/�1.YSVa'//�, lN�} � � �r i <br /> Vendor Mailing Address Ciry State Zip i <br /> ��S1�sL_1.�'0� � <br /> � <br /> Phone Email <br /> i <br /> � <br /> i <br /> I, the Vendor, agree to receive the Bsckraater Prevention Device rebate check direc0y for the <br /> installation at the above reterenced propery address. By aoreeing to receive the rebate check � <br /> direcUy, I agree to the follav�ng: <br /> 1. The Back�.vater Prevention Device reoata amount will be deducled from the final invoice I <br /> oiven to the property ov✓ner for the installaiion at the prope�iy address referenced above, if i <br /> the total cost of the Installation is greater than the rebate. ; <br /> 2. I,the Vendor, am a VVashington State licensed contractor. � <br /> 3. The Ciry of Everett will send a Federal Form 1099 h115C lo me, U;e Vendor, for Backwaier � <br /> Prevention Device rebate paymeNs totaling mora than 5600 per calendar year, and�vill t <br /> report the same paymen�s to the Intemal Revenue Service ' <br /> I accepl the payment oF the Back�vater Prevenlion Device rebate(rom the Cily of Everelt penoiny � <br /> approval o�Ihe completed Backv�aler Prevenlion Uevice rebate package by ihe City of Everett <br /> � <br /> ( <br /> i <br /> ���'r��� i <br /> Signature of Conlraclor , Date <br /> 1 <br /> I <br /> . � <br /> i <br /> I <br /> � <br />