Laserfiche WebLink
i <br /> . � ' Backwater Prevention Device <br /> ' Rebate Program <br /> � <br /> � <br /> Ven�dor Section (please print): <br /> ��' �e�1F6ELL�, _�U�1 � �( i �i�'L / Uj OZ ����.0 � 1� <br /> Ver:�Jor Narne!Bu,iness Name/ UBI Number <br /> �_���t�r�A �.� ,� �,� <br /> , �— <br /> Slale of Washington Coniractor License Num6er. <br /> '!; L E�r�t—�'»`�{ I �v���iT i�A �"l�SZL`(� <br /> Vendor Mailiny Address City State Zip <br /> �1��..5 -'L5�i- �g�g S�rv�te r�� �U�,pj)�115 l�l����b�'ti�� , <br /> �i Cu✓✓1 <br /> Ph'one Email <br /> I <br /> I, thelVendor, agree to receive the Backwaler Prevention Device rebate check direcUy <br /> for the installation referenced at the Properly Address. By agreeing to receive the rebate <br /> check directly, I agree to the following: <br /> i <br /> 1.j The [iar,kwater Prevention Device rebate amount will be deducted from the (inal <br /> ' invoice given to ihe Property Owner for the installation at the Properly Addrsss <br /> : referenced above, if the total cost of the installation is greater than the rebate. <br /> 2.� I, the Vendor, am a 1Nashingtan State licensed contractor. <br /> 3. The City of Everett tvill send a Federal Form 1099 MISC to me, the Vendor, for <br /> i the Backwaler Prevention Device rebate payments totaling more than $600 per <br /> calendar year, and will report the same payments to the Internal Revenue <br /> Service. <br /> I acce��l the direct payment of the Backwater Prevention Device rebale from Ihe City <br /> of Everett pending aj�proval of the completed Backwater Prevention Device rebate <br /> pacl�age by thr ���f Evereit <br /> �..•— '" / <br /> ; % <br /> , - ' _.^ _. ... <br /> r� � /.__ .. •.. <br /> -�,. � ��; __ �� � <br /> Sign�tu of Conhaclor Dafe � <br /> � <br /> i — <br /> � <br /> I <br /> � <br /> Revisedl9/3/2014 . �'age 2 of 2 <br />