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4 <br />1 <br />Contractor Section: <br />IM l7'�n i' ��.n�, (� � b V <br />. Vendor Name / E3usiness Na�e I UBI Numbcr <br />r; �-� I'�.�- Fs�3 T cu__ <br />� State of Washinglon Contractor License Number: <br />� <br />�, <br />I �%S( S �f� 3f' S�', SF --Sn_��'^�(� L"/%b - G�'�2°r(J <br />Vendor fviaiGng Address City State Zip <br />7 <br />Phone <br />'�n <br />Email <br />r�.,-,b � � � �, <br />I, Ihe Vendor, agree to recewe the Backv�ater Prevention Device rebate check directly for Ihe <br />installation at the abm�e referenced property adAress. By agreeing to receive the rebale check <br />direclty, I agree to the following� <br />1 <br />2 <br />3 <br />The Back�roater PrevenUon Device rr.bale amount wiil be deducled from the final invoice <br />grven to the property owner for the installafion at the propeAy address�referenced above, d <br />the lotai cosl of the ,nstallahon is greeller th�n Ihe rebaie <br />I, lhe Vendor, am <� YJashington State licensed conlraclor. <br />The Cily of EvereU v� il send a Federal Form 1099 MISC to me, �he Vendor, for Backu�ater <br />Prevention Device rebate payments totalir�� more Ihan 5600 per cale �dar year, and �vill <br />report �he sama paymenls to the INeinal Revenue Senace <br />I accept ihe payment ol lhe Bar.kwatrr Preventinn Devir.e rehate from the City of Fverelt perding <br />approval of Ihe completed 6ack�valer Prevenl�on Device rebate packac�e by the City of Fverett <br />—���-- <br />Signalure o( Conlractor <br />--- �c_S-/s <br />