Laserfiche WebLink
, , . � - <br /> Backwater Prevention Device <br /> Rebate Program <br /> Vendor Section (please print): <br /> (�o/(rn.r +�oS-� � • �cs2o PCv�+4�►•u <br /> Vendor Name!Business Neme/UBI Number <br /> {4��eDrP�g(3k2 <br /> Stete of Washington Contradw License Number. <br /> R7 �or g8� SwvNom�sA wa. 9uZ91 <br /> Vendor Melling Address City 3tate Zip <br /> a�D�e—�(O ' O�Z`� 'T�`rCo��l/rs� �(ARoo r C arv� <br /> Phone Emall <br /> I,the Vendw, agree to recefve the Backwater Prevention Device rebate chedc directly <br /> for the instellation reterenced at the Property Address. By agreeing to receive the rebate <br /> check d:rectly, I agree to the following: <br /> 1, The Backwater PrevenUon Device rebate amount will be deducted from the final <br /> Involce given to lhe Property Owner for the Installa8on at the Property Address <br /> referenced above, ft the total cost oi the(nstalletlon is greater than the rebate. <br /> 2. I, the Vendor, am a Washington State Iicensed contreclor. <br /> 3. The C(ty of Everett will send a Federal Form 1099 MISC to me,the Vendor,for <br /> the Bac;cwater PrevenHon Device rebate payments totaling more than 5600 per <br /> calendar year,end will report the same payments to the Intemal Revenue <br /> Service. <br /> I accept lhe direct payment of the Backwater P►evention Oevice rebate from the City <br /> of Everetl pending approval of the completed Backwater Prevention Devfce rebate <br /> packege by ihe City of Everett <br /> �z- 7�--i� <br /> Slqnature o Confrecfor Dete <br /> Page 2 of 2 <br /> Ravised 9/3I2014 <br />