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Contractor Section: <br /> ��n�/� %�urrii3,i� � f�a��.�e G' (�6o p�/ 97�, 1 <br /> Vendor Name/Business Name!UB umber <br /> �-��/rl�i� ��y�Pa <br /> State of Washington Contractor License Number. <br /> /l�C.,/�f_ /3 %�' /��. 1-� ��n�cvop� Lvfl 1�os 7 <br /> Vendor �dailiny Address Cily Stale Zip <br /> - �/zi" 7�s=��y�S( ;:� � �� day��d,,,k ,��f- <br /> Phone --� <br /> Email <br /> L------ — — —-- –— - ---- — — — <br /> I, the Vendor, agree io recolve the Back�vater Prevention Device rebale check directly tor the <br /> installation al the above referenced proparty address. By agreeing to recoive the rebate check <br /> directly, I agree to the following: <br /> 1. The Back�vater Prevenlion Device rebate amount�vill he deducled (rom the final invoice <br /> given lo Ihe property o�vner for the insWllalion at the property address referenced above, i( <br /> the total cost of Ihe installation is greater Ihan lhe rebale. <br /> 2. I, ihe Vendor, am a N.�ashington Slale licensed contractor. <br /> 3. The Cily of Everetl will send a Federel Form 10�J9 PdISC to mo, Ihc Vendor,for Backwaler <br /> Provenlion Device reb�lc paymenls lolaling mu�e lhun $600 Ver calendar year,antl will <br /> report the same paymenls to the Inlernal Revenue Sorvice. <br /> I accepl the payment of tl�e Backwaler Prevontion Dovice rebate from Ihe City of Fvercll pandini� <br /> approvai ol lhe compleled Aackweter Prevenlion Device�ebnte patkage by the Cily ot Everett <br /> l � !� �v�Cl.c� _J�/� �-- <br /> Signature of Conlractor Date <br />