Laserfiche WebLink
Contractor Section: <br />I <br />` ��C�.-.`��-C�-f'�- �jC=tt, % LL-C. ��'_'—.3L�t�3�� <br />�iC�Lt'�1-- �C- -- i <br />Vendor Name I F3usine �s Name I UBI Number I <br />��1r �, �. , i <br />��_ .�-�- � �- � -K �---- ----- <br />Slale o( Washinglon Contracror License Number. <br />1�� <br />� __�(v'D(r� __�--�d C�i_P-1—��,.---��'�'-r'�tt'_(,�%c—t'�•-�Cj <br />Ver�dor Mailing �ddress City itate Zip <br />�'a�,_���t�g� C'a�'�I_�1'�s�_�:��_ cr��Qa- ��� <br />IPhone Email <br />I, ihe Vendor, ayree to receive the Rack�vater Prevention Device rebate check directly for the <br />ins;allation at the above referenced property address. Dy agreeing lo receive tF�s rebate check <br />�Irectly, I agree to the follov:ing� <br />The Backwaler Prevention Device rebate amnunt will he deducted from the Gnal mvoice <br />g�ven to' ie property a•mer for the installation al the property address re(erenr,ed ahove, if <br />the totai cost of the inslallalion is greater lhan the rebate <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3. The City of [verett ivill send a Federal Form 1099 MISC to me, ihe Vendnr, for Backwater <br />Prevention Device rebale payments totaling more than $600 per calendar year, and will <br />report the same payments to ihe Intemal Rcvenue Service. <br />r-- — ------ - - - ---- <br />� I accepl the paYmeni of lhe f3ackwaler Prevrntion Device rebate �rom ihe Cdy of [verefl pendmg <br />opproval oi the completed Back�vater Prevenlion Devicc rebale p�ckage hy lhe City oi [vereti <br />i <br />� -_` 4 - � � � � ----- - --� ��=�_--- <br />Sic�nalure of CoNractor Date <br />