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Contractor Section: <br /> /�r;,Ll.��L[s.r✓►�.��/_G --- ----�> �ri/ 3 - vSSl <br /> Vendor Name I Buslness Name/U61 Number <br /> �t1�GG_t�_���: -- --- ---- — <br /> Stato of Washington Contrector �icense Number. <br /> s��f�__7���V,_NL_� ���5 I/L///'- W� :S�iG <br /> Vendr.r Mailing Address City Stato Zip <br /> �`�z.�3�57__��1.�c�7 ---- ---- -- __--- -- <br /> Phone ' Email <br /> I, the Vendor, agree to reczive the Backa�ater Prevention Device robate cneck direclly fnr ihe <br /> ins!all�lion at the above re(erenced proper[y address, By ayreeing to receive the rebate check <br /> direclly, I agree to the tollo�ving: <br /> 1. The Backv�aler Prevenl�nn Device rehale amounl�vill be deducled Irom the final invoice <br /> given to lhe property a�mer for Ihe installation at the property address referenr,ed above, if <br /> the total cost of lhe installalion is greater than the re6ate. <br /> 2. I, the Vendor, am a Washington Slale licensed contractor. <br /> 3 The Cily of Everelt will send a Federal Form 1099 NISC to me, tho Vendor, tor Back�v.der <br /> Prr.vcntion Devir,� rcbate payments totaling more than SG00 per catendar year, and edill <br /> repu�i Ihe same paymznls fo ihc :niernal Revenue Servic�. <br /> -- -.____-- ---- -- --------- � <br /> II ��ccept fhe paymenl of Ihe �eckwaler Prevontion Devico rehate (rom Ihe Cily of Everelt pending ' <br /> approval of the completed Back�vater Prev�:nlion Davice rebale par.kage ny the Cily ot Everelt <br /> � <br /> � — - - --- - _ � _ � • � 5 -- <br /> Slgn�ilure oi Contractor --- Dale <br />