Laserfiche WebLink
� �ackw���r Prevention DE:vice <br /> � �:ebate Program <br /> Ver�dor 5ection (��lease printj; <br /> LJ�ir��{�F'+�LL� >LU111t�1IL(it �NC . 1 Gj U Z ����U Cl�t� <br /> Ver,aor Name/ Business Name ! UBI Nurnber � <br /> _ C_A mP G�_i= �-t I�i�n�--- <br /> State of Washington Contractor Lice�se Number: ' <br /> , lti . l�is ��5�-{ I �v�i'�i�--- ""�' `� x�—� <br /> Vendor Mailing Address City Stale Zi <br /> � + P I <br /> (��`j_� .�i�l - �!S`�� jLj��l�`�'�'cj�C\�a� ����I�� � �V�ti1f)��l " Ci�ia'� <br /> ---- —�=—� �_— <br /> Phone Email <br /> --- --- I <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebaie check directly <br /> inr the installation referenced at the Property Address. By agreeing to receive the rebate <br /> r,heck directly, I agree to the follov✓iny <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final <br /> invoice given to the Property Owner for the installation at the Properly Address <br /> referenced above, if the total cost of the installation is greater than the rebate. <br /> 2. I, the Vendor, am a Washington St�te licensed contractor. <br /> 3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for <br /> the f3ackwater Prevention Device rebate paymenls totaling more than $600 per <br /> r,alendar year, and will report lhe same payments to the lnternal Rc;venue <br /> SBNICP.. <br /> I accept lfie direcl paymeni of ihe Backwaler Prevention Device rebate from the Cily <br /> of Everett pending approval of the completed Backwater Prevention Device rebate <br /> peackage by the City of Fverett <br /> � C l -lZ-iS- <br /> —�—� — — --�.__. <br /> Siynature of Contractor Date <br /> I <br /> Revi;ed 9/3/2i114 <br /> Paye 2 of 2 <br />