Laserfiche WebLink
� <br />E�ackwater Pr�vention Dev�ce <br />Reba��e Progrlm <br />Veridor Section (pleas� prin4�: <br />,TTLE URAIN SERVICE 602830936 <br />Vendor Name / Business Name / UBI Number <br />State of Washington Contractor License Number: <br />Vendor Mailina Add <br />Phone 206-632-8069 <br />�7' 8"!, <br />I, the Vendor, agree to receive the Backwater Prevenlion Device rebate check directiy fcr <br />the installation referenced at Ihe PropeRy Address. By agrE+eing to receive lhe rebate <br />check directly, I agree to the following: <br />1. The Sackwater Prevention Device rebate amount vdill be deducted from the final <br />invoice given to the Property Owner for the installation at the Properiy Address <br />referenced above, if ihe total cost of the installation is greater than the rebate. <br />2. 1, the Vendor, am a Washington State licensed contractor. <br />3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for <br />the Backwater Prevention Device rebate payments totaling more than $600 per <br />calendar year, and will report the same payments to the Internal Revenue <br />:�ervice. <br />I accept the direct payment of the Back�vater Prevention Device rebate from Uie City of <br />Everett pending approval of the completeJ Backwater Prevention Device re6ate <br />package by the City of Everelt <br />Signature o�" Confracfor <br />Revised 9/3/2014 <br />� .5 -�-��5 <br />Date <br />Page 2 of 2 <br />