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i <br /> ; <br /> � <br /> , <br /> � <br /> ; <br /> Contrector Section: <br /> � — --._._ - ---- --- ; <br /> �,�� � <br /> �C' "} ,;�( F. S�L� '-t���=---�'�Ci_'�_.;-_f�t' :.�.� <br /> Vendo��Name�1 Dus�'�ame/UBI N�mber ; <br /> i <br /> � ; <br /> A ���.z�-��--K�- - ; <br /> Slate of Washington Contraclor license Number. • <br /> a�•o� L4r.1��1-�-� - .�k�'�tf'_��.��,����a_:� <br /> Vendor Mailing Address City State Zip <br /> ar�_a�.l�••,�nga L�«�clssi_c:�.�a�_ �, • �-sc�n'1_ <br /> Phone Email ; <br /> i <br /> � - -- , <br /> I, lhe Ventlor, agree to receive the Dack�vater Prevenlion Device rehate check directly for the <br /> inslallation at the above referenced property address. Dy agreeing to receive the rebafe check <br /> directly, I agree to the following� <br /> 1. The Backwater Prevcnlion Device rebale amount�vill be deductod irom lhe final invoice <br /> given to the property ovmer for the insfall�ilion al Ihe property address refcrenced a6ove, if <br /> the lotal cost of Ihe installa�ion is greater than the rebate. <br /> 2. I,lhc Vendor, am a Washington State iir.ensed r.ontraclor. ' <br /> 3. The Cily of Everett will send a 1"oderal form 1099 MISC to me,Ui�Vendor, for Backwater <br /> Prevention Device rebate paYments totaling more than 5600 per calendar year, and�vill <br /> report lhe same payments to the Internal Revenue Service. <br /> I accept the payment of Ihe 8ackwatcr Prevention Device rebate from the City o(Evored pending <br /> approval of lhe completed Backweler Prevenlion Device rehate package by i'',a Ciry oi Evuie[t <br /> i <br /> C�� �� � �'�::..� _ _� '�� _ � <br /> Signa�ure ot Conlraclor Date <br /> i <br /> i <br /> i <br />