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Contractor Section: <br />-, <br />�c�_LLU �_cd.�l.ltl_v CX�3 -rii � -v.5.<l <br />Vendor N2me I Ausiness Name I UBI Number <br />�}�i/L!-'L�,y_G�L� — -- <br />State of N�asl��ington Contrac;or License Number. <br />s_�t<�z:z��-'��- �= N�=-- _.���lzys ��u,� iN� �� ��� <br />b'endor A4ailinc� /�dclress City State Zip <br />� �-`�_ �.5�_ '��'Z-'%��'i % _ <br />�I Phone ` Email <br />� <br />L-- — <br />I, the Vendor, agree ;o receive Ihe Back�vater Prevzntion Device rebate cneck direcUy tor the <br />nsf :liation al fi•�e above re(ererced property address. By agr�eing to receive the reb�te :heck <br />directly, 1 agree to the folloe,ing: <br />1 The Backerater Prevenlion Device rebate amount will be deducled frcm lhe final Invoice <br />given fo Ihe property ocrner (or the inslallation at the propc�rty address referenced above, if <br />ILe total cost of fhe Installation is greater than the rebato. <br />�. I, th= Vendor, am a V��ashington Sta;e licensetl contractor. <br />',. The City of Fveret, aill send a Federal Form 1099 t�71SC to me, the Vendor, tor Back�valer <br />Preventinn 17evice rebale paym^ it; tofalinr� more than BG00 per calenUar year, and �vill <br />report Ihe same payments lo the !;�iemal R�venuc Service. <br />iI a�c^.pt ,na payment of Ihe �acka�ater F: avenlion Devico rebate `rom the Cily of EvereR pending <br />,approw:l of the compleled fiack�^�aler Prevenlion Device rebcto paGtage hy the Ciry oi Evern't <br />, �� , 1 _7 � �r <br />Si��nofure of Conlracbr _, Date <br />