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Contractor SecHon: • <br /> _ Anr;.�,7; ���,��;�, ��iGL�,-v :�4:�38 <br /> Vendor Name!eusiness Name/Uel Number • <br /> ,; <br /> �Mz F,y�S �� _ <br /> SNate of Washington Contractor License Number. <br /> ��,��o �rl..p ,1�� Ei.�r� � I�fl G1�3 <br /> Vendor Mailing Address Ciry State 2ip <br /> . � n��, �� ��'..��tr.�m�r�c�,� ��,h�ywJ_��,� .c�m <br /> � <br /> Phone Email <br /> � <br /> ; <br /> I,the Vendor,agree to receive Ihe Beckwater Prevenbon Device rebale check directly for the <br /> instaliation at the above referenced prqperty address. By agreeing to receive the rebate ciieck <br /> directly, I agree to the folbwing: � <br /> 1. The Backwater Prevention De�ice rebate amaunt will be deducted from the final invoire <br /> given to the property owner tor•the instellation at the property address referenced above,if <br /> �� the total cost of Me installation is greater then the rebate. <br /> � 2, I,the Vendor,am a Weshington Stete licensed conhactor. . � � <br /> 3. The City of Everelt will send a Federal Fortn 1099 MISC to me,the Vendor,for Baekwater ' <br /> � Prevention Device rebate payments totaling more ihan 5600 per calender year,and will � <br /> report the�ame payments to the Intemal Revenue Service. <br /> I accept the payment of the Bach.vater Prevention Device rebate from the Ciry of Everett pending <br /> � appmval of the completed Backwaler Prevention Device rebate package by ihe City of Everett : <br /> �,�� - �-� -�-a--��- <br /> Signature of CanUacior Date <br />