Laserfiche WebLink
� <br />� <br />Backwater Prevention Device <br />Rebate Program <br />Ven�lor Ser.tion (please print): <br />� <br />_�rNr"�j�� LUA1 pl;i-� Ir,�C_ <br />Vendor Name / Business Name 1 UBI Number <br />C_ � i�1(� (�j�% _i G i-1 ton < <br />State of <br />nington Contractor License Number: <br />� `�5�i I �v�'=-�T <br />Vendor Mailing Address <br />�Z.`� - Z.5 �I - �;S`i' <br />Phone � <br />City <br />�rvi�e <br />Email <br />� a Z�12.1v 1 �1`E <br />�.a _�i;s�� <br />State Zip <br />ell5 Ql�,,,nl�,v�c . �.•�. <br />I, the Vendor, agree to receive Ihe 3ackwater Prevention Device rebate check directiy <br />for the installation referenced at the Property Address. 8y agreeing to receive the rebate <br />check directly, I 2aree to the following: <br />i <br />2. <br />3. <br />The Backwater Prevenlion Device rebate amoimt will be deducted from the final <br />invoice given to the Property Owner for the mstallation at the Property Address <br />referenced above, if the total cost of the installation is greater than the rebate. <br />(, the Vendor, am a Washington State licensed contractor <br />Th� City of Evereri will send a Federal �'orm 1099 MISC to me, the Vendor, for <br />the Backwater Prevention pevice rebate payments totaling more than 3600 per <br />calendar year, and will report the same payments to the Internai Revenue <br />Service. <br />I accept the direct payment of the Backwater F'r_•vention Device rebate from the City <br />of Lverett pending approval of the completed Backwater Prevention Device rebate <br />package by the Ci f Everett <br />-__--%�;I <br />_� <br />o/ Contrac7or <br />� <br />Z� ���� � <br />D te <br />Revised 9/3/2014 Page 2 oi 2 <br />