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Contractor Section: <br /> i ���LL_U_1�Gl�M j �nl� l�3 -OI � - uSSf <br /> � Vendor Name/Business Name/UBI Number <br /> �rr��_G� v�� I <br /> State ot VVashington Contractor License Number i <br /> S�o ,s rffi/, Nj_ M/d1��5 i.'�/ �s' lN��� rJ <br /> Vendor A�ailing Address City S±ate Z1p <br /> ��1 � ����7 I <br /> I Phone ` Email <br /> � _ I <br /> I, ihe Vendor, agree to receive the Backw2ler Prevention Dsvice rebale cneck dir2cily for the <br /> �nsial!ation at the above referenced property address. By agreeing to receive tne rebate checK <br /> directly, I agree to the folio�vino: <br /> 1. The Baoktvaler Preven6on Device reb3ta amount wili be deducted from the final invoica <br /> given to the property o�vner for the inslallatron at the property address referenced above, Ii <br /> the total co;t of Ihe installation is greater than the rebate. <br /> 2. I, the Vendor, am a 1Nashinglon State licensed contractor. <br /> 3. i he City oi Fverett will send a Federal Form 1D99 NISC lo me, ihe Vendor, tor Backwater <br /> Prevention Device rebate payments totaling more ihan S6CG per caiendar year, -r.nd �wl! <br /> report the same peyments to the intemal Revenuo Service. <br /> I accept the payment of the P.ackwater Prevention Device rebate from thu City oi Gv�rett pending , <br /> approval of lhe compieted Back�vater Prevenlion Device rebate package by the City of Ever�lt <br /> . i <br /> � C�-1).� 15 <br /> Signature of Contractor _ Oate <br /> I <br />