Laserfiche WebLink
i <br /> Contractor Section: <br /> M�� i���,,,, h. ,,�, � oa �sr�; �a�r, <br /> , <br /> Vendor Name/ Business Na e/UBI Number <br /> Mo�/� �'P� Ss}S 3 J r� I <br /> State of Washington Contractor License Number: <br /> i �S � s �,t `—'� SP. sc 5,���,��� s� wl4 �Y7-�l o <br /> Vendor Mailing Address City State Zip <br /> �I � S� 7(>O ���•O 1r�n��J h� u(,n ����,-,l�ir��. c���h <br /> Phono Email <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <br /> instaliation at the above referenced property address. By agreeing to receive the rebate check <br /> directly, I agree to the following: <br /> 1. The Backwater Prevenlion Devi�e rebate amount will be deducled from ihe fii�a!invo(ce <br /> given to the property o�vner tor the installation at the property address referenceo atove, if <br /> the total cost of the irstalialion is greater than the rebate. <br /> 2. I, 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 Backwater <br /> Prevention Device rebate paymenls totalinc� more than$600 per calendar year, and will <br /> report the same payments to the Intemal Revenue Service. I <br /> � <br /> I accept the payment of the Backwater Prevenllon Device rebate from Ihe Cily of Everelt pending <br /> approval of liie completed Backwater Prevention Device rebate package by the City of Everett <br /> �� ''�/��j��,; j _c;�� �S <br /> Signature oFConlraolor Date <br />