Laserfiche WebLink
Contractor Section: <br /> oz- � - 3 <br /> �,v-n� �N��i�u�'�t , i� ,o�c�mhl�i'jlC 9� �� �� � �r3 7 <br /> �ndor NamQ/Business Name/UBI Number <br /> �9r9/� �✓l� D/l PF� <br /> � <br /> State of Washington Contra�tor License Number: <br /> ��l l l/i,S'fziv2n� f9�� �"U.�.�T 1,�t9- ��'Z oz3 <br /> Vendor Mailing Add2ss City State Zip <br /> G�ZJ`/-��I� -D!'Z3 �plLn-,/�i�� • !-LLa-y7e 7,��r ccn� <br /> Phone Email <br /> I,the Vendor,agree to receive the Backwater Prevention Device rebate check di2dly for the <br /> instailation at the above referenced property address. By agreeing lo recefve the re6ate check <br /> directly, I agree to the Tnllowing: <br /> 1. The Backwater Prevention Devioe rebate amount wiil be deducted irom the finel invoice <br /> given io the property owner tor the installa6on at the property address referenced above, if <br /> the total cost of the inslallation is greater than the rebale. <br /> 2. I, lhe Vendor, am a Washington State licensed contractor. <br /> 3. The Cily of Everett will send a Federai Form 1099 MISC to me,the Vendor,for Backwater <br /> Prevention Oevice re6ate payments totaling more than $600 per calendar year, and will <br /> report the same payments to tlie Intemal Revenue Service. <br /> I accept the payment of the Backwater Preven6on Device rebale from the Ciry of Everett pending <br /> approval of the completed Backwater Prevention Device rebate package by the City of Everett <br /> � t <br /> �_ /-2�--�5� <br /> Signature of Conhactor Date <br />