Laserfiche WebLink
i <br /> � <br /> i <br /> I <br /> ( <br /> Contractor Section: j <br /> i <br /> I `. ��. �� ;�1�,' �--�--1.`. � (,��C'�c� �,��] ��� � <br /> Vendor Name/Business Name/ UBI Number i <br /> L � <br /> `��wnr;= L � I ly r,�� i <br /> � <br /> State of Washington Con;ractor Li�ense Number: <br /> -.��� 1`L,� ����_� ��lliiiiti�.�'�?� �'�'� �:��',�`f (a', � <br /> Vendor Mailiny Address City State Zip j <br /> �'�(%��' i'"GfC�-- 'l�-�;�' ��t i���,';x:.w�;-�'E ���'+�u� I; , � <br /> . � ��('f:'1.7 i <br /> �Phone Email ; <br /> � <br /> I <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate check directty (or lhe ' <br /> installation at the above referenced property address. By agreeing to receive Ihe rebate check '' <br /> directly, I agree to the following: ' <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final invoice I <br /> given to lhe property owner lor the instaliation at fhe property address referenced above, iF � <br /> Ihe lotal cost of the installation is grealer lhan ihe rebate. <br /> 2. I, ihe Vendor, am a Washington State licensed contra�lor. ! <br /> 3. The City of Everott will send a Federai Form 1099 MISC to me, the Vendor, for Backe�ater j <br /> Prevention Device rebate payments lolaling more than $600 per calendar year, and will � <br /> report lhe samo paymenls to lhe Internal Revenue Service. � <br /> —— � <br /> I accepl ihe paymeni of the Backwaler Prevention Device reLate from the City of �verett pending j <br /> approval of the compleled Backwater Prevention Device rebale package by Ihe Cily of F_verett � <br /> � <br /> `' ; <br /> ,�i--� ����� ; <br /> � , „ , <br /> ti <br /> Signature of Conlractor Dale � <br /> � <br />