Laserfiche WebLink
1 <br /> i <br /> ( <br /> i <br /> i <br /> Contractor Section: � <br /> i <br /> ` �jN iC7(�� �__ -LL �U/✓��----•i3<<F� � <br /> - - �.��s�.-._" ► <br /> Vendor Name I eusine s Name/UBI Number ' <br /> � <br /> _A_J�-r'-<-��-�---._�� � I <br /> ,,��K L- --- � <br /> State o( Washington Conlractor License Number. <br /> � � <br /> ��i_1P I-�rl��_�_-D�,• �._N�-s��-1-f-��� �'k• '� i <br /> Vendor Mailing Address City State ZiP <br /> � <br /> � c I��-s-�t'L�-- " <br /> �-�:�o--a?c��.a�._C��1'�►i�1c�E�.�?�_.-��t -- � <br /> Phone Email ': <br /> I <br /> I, lhe Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <br /> installafion at fhe above referenced property address. By agreeing to receive'fhe rebate check + <br /> directly, I agree to the follov�ing� � <br /> � <br /> 1. The Backwater Pmvenlion Oevice rebale amount will be deducted from lhe final invoice � <br /> given to the property owner for the installation at lhe property address referenced above, if ` <br /> the tolal cost of the installation is g�eater than the rebate. � <br /> 2 I, !he Vendor, am a VJashington State licensed contracfoc i <br /> 3. The City oi Everetl wiil send a Federal Form 1099 MISC to me,the Vendor, (or Backv�ater � <br /> Prevention Device rebate payments iotaling more than b600 per calendar year, and will <br /> repori the same paymenls to lhe Inlemal Revenue Service. � <br /> I accept the payment of the Backwater Prevention Device rebate from the Ciry of Everetl pendin9 i <br /> approval o(lhe compleled Backwater Prevenlion Device rebate package by Oie City of Everell i <br /> I <br /> ,� � _ � <br /> -�-�- �s--- � <br /> (�P�-�- ' �--�_� � � <br /> Dale ; <br /> Signature of Conlractor � <br /> I <br /> , <br /> � <br /> ' ' i <br /> . � <br />