Laserfiche WebLink
i <br /> ��.� Backwater Prevention Device ; <br /> � � R:ebate Program � <br /> , <br /> � <br /> Vendor Section (please print): 1 <br /> _C_ ���FB`u`S t'L-Ufl1FUL'•(•l Ir�c . (y �� �1Zln �T�I`� � � <br /> Vendor fJame/Business Name / UBI Numb� � <br /> _ C_Ar�1P�>P :L �ll�l �1,��_` j <br /> Slate of Us-ashington Contractor License Number. i <br /> �(�_�c:-N `�5y j �v�"1?`i i- v--,=\ �I�S2L � <br /> _ �_ <br /> Vendor fvlailing Address City State Zip <br /> Z5 �S��i - �%s9F�' j�rv��; JCU,M I ells I b. � _ ' <br /> �-L-_— _ J � v�� � �,cu��n � <br /> _ � <br /> ' Phone Email <br /> I, the Vendor: agree to receive the Backwater Prevention Device rebate check directly <br /> for the installation referenced al the Property Address. By agreeing to receive the rebate <br /> rlieck directly, I agree to the following: , <br /> 1 . The Backwater Prevention Device rebate amount will be ded�_cted from the final j <br /> invoice given to the Property O�vner �or the installation at the Properiy Address ' <br /> referenced abode, if the total cost of the installation is greater than the rebate. ' <br /> 2. I, the Vendor, am a Washinglon State licensed contractor. <br /> 3. The City ot Lverett will send a 1=ederal Form 1099 A41SC to rne, the Ven�or, for ! <br /> lhe E3ackwater Prevenlion Device rebale payments totaling more than $600 per <br /> calendar year, and will report tlie samc: payments to the Internal Revenue <br /> Sen�ice. j <br /> ! <br /> I accepi the dirert payment of the Backwater Prevention Device rebate frnm the City � <br /> of Evr.rett pendiny apprcwal of the completed Back�vater Prevention Device rebate <br /> � <br /> pack�p�-tf�e-�11y o Everett <br /> / <br /> -- — --- - — — -- - .��`Y �J _ i <br /> Siqnatw o/Cont�ac(or D��le � <br /> ! <br /> -� i <br /> i <br /> i <br /> I <br /> 1 <br /> PB�B 2 O�2 � <br /> Revised 9I3120 i4 { <br /> i <br /> I <br />