Laserfiche WebLink
Backwater Pre4•ention Device <br />Rebate Program <br />Vendor Section (please print): <br />a�L �1Z1� `��l`� ~ <br />Vendor Name I Business Name / UBI t�umber � <br />C. A ���,� 6 (� L � U � �1n S _____ __ _ _ _ <br />State of Washington Contractor License Number <br />.L�. �i>ti �J�`-iI �ilc�Lj� --_i.�� `l�j� <br />Vendor M�ailing Address City S���P 7iP <br />"�'� _%�j- _7:5�(j �c'_��b'IIC�cJ�U�� �Jl,������ �ViN�)i�14 � C.u�'v� <br />.�— -- � --.J----- <br />Phr,ne Email <br />i, the Vendor, agree to receive the Backwaler Preve�tion Device rebate check direcUy <br />for the install�tion referenced at the Propeny Addre�s. f3y agreeing to receive tha rebate <br />check directly, I agree to the following: <br />1, The Bar.kwater Prevention Device rebate amount will be deducted from the final <br />invoice given to the Property Ovdner (or the installation at U,e Property Address <br />re(erenced above, if the [otal cost of the installation is greater Ihan lhe rebate. <br />2 I, the Vendor, am a Washington State licensed contractor. <br />3 The City of Everett will snnd a Federal Form 1099 �-71SC to me, lhe Vendor, for <br />the Backwater Prevention Device rebate payments totaling more than $600 per <br />calendar yf:ar, and �viN report the same payments to the Internal Revenue <br />SF;NICP,. <br />I acr.e�it the direcl payment of the Backwater i'revention Device rebate from the City <br />of �verett pending approval of the complefed f3ack�vater Prevention Device rebate <br />package by the C1Ly.t f[:verett <br />,_.--�� ;!l <br />nl Conht�r,tor <br />Revised 9;:5�201d <br />. ----- i�,,a� <br />Page 2 ot 2 <br />