Laserfiche WebLink
Contractor Section: <br />I Vendor Name I Ciusine�s Name I UBI Number <br />.. <br />A,1��� _; i `��`� ��--1�-� -- <br />Slate of Nlashington Cun�raclor License Number. <br />�Lv1�_4� Lr�1` <br />Vendor iNailing Address <br />Phone <br />Ciry State Zip <br />+:�cJs!'iS.�_v�:.?, �_�/•�r.�_��G"c1��1.i1�- <br />Email <br />I, the Vendor, agree to receive the [iack�valer Prevenlion Device r2f�ate check direciry for the <br />installalion at the above referenced property address. By agreeing fo receive fhe rebate check <br />directly, i agree to the tollowing <br />1 <br />2. <br />3. <br />The Backv�ater Prevention Device rebate amount will he deducled from the final invoice <br />given to the property owner for lhe insfallalion at ihe property address referenced ubove, if <br />Ihe total cost of the inslallation is c� ealer than Ihe rehale <br />I, the Vendor, am a Washinglon State licensed cont�aclor. <br />Tf•,e Ciry of Everclt will send a Federal Form 1D�J9 tv11SC to me, lhe Vendor, for Rackwater <br />Preveniion Device rebate payments totaling more than $600 per calendar year, and vdill <br />rc;pori �he same payments to the Internal Revenue Service. <br />I accept Ihe p�Y�nenl of the Backwaler Prevenlion Oevice rebate (rom the Cily of Everett pending <br />approval o( t��e completed E3ack���ater Prevenlion Device rebate package by the Cdy of Everell <br />� Cd � � � <br />��.-�__ �---- <br />Si�nature ot Contractor <br />I--- ----- --- <br />= =!-f �u _ <br />Dale <br />