Laserfiche WebLink
i <br /> ; <br /> i <br /> � <br /> Contractor Section: � <br /> I <br /> /�1��l,1.U�/� Lnlv ��� —�i% > — �iSSf i <br /> Vendor Name I Business Name/UBI Numbsr � <br /> � ' ; <br /> C�IiL � �' c�'1� � ; <br /> Stata of hl�ashington Contractor License Number, j ! <br /> I � <br /> ' N - MAIZYSViL ' W/; `�.4?:�% � <br /> � r <br /> S`G 1_f���_ L �l'� I <br /> Vendor Ulailing Address City State Zip � j <br /> � <br /> i "��. ' �_1.�CJ7 � <br /> i Phone ' Emaii j <br /> I t <br /> � <br /> e <br /> I, the Vender, agree to receive tne B2ck�vater Prevenlion Devic� rebate ch2ck direcUy for,he � <br /> inst�llation at the abov2 referenc�d propery address. By aoreeing to rec2ive the rebate check � <br /> diiectly, I agree+.�the tollotivina: ; <br /> 1. The Back�vater Prav2nlion Devic� rebate amount will ba deducted fto.m t'ne fr.al invnica <br /> glven to the propery o�vner for the installation at the prooerty address re`erenced above, I` i <br /> ths tot21 cosl o(the installation is grezier than the reba?e. � <br /> 2. I, tne Ver.dor, am a Washington Stat2 tieens=_d conVactor. � <br /> 3. The Ciry of Everett�vill send a Federal Form 1C99 MISC to me,the Vendor, (or Backwater � <br /> Prevention Device rebate payments totaling more than 5600 per c2lendar year, and�ti-ilt <br /> report the same payments to the Internal Reverue Service. i <br /> i <br /> I accept the payment ot the Sack�vater Prevention Davlce rebata frem the City oi Everett pendi i�� ' <br /> aooroval of tha completed Backe�ater Prevention Device rebate packag> by the City oi Everett � � <br /> i <br /> � <br /> f <br /> -S- IS� is � <br /> — r <br /> i Signature of Contractor Dale ' <br /> I <br /> � <br /> I — � <br /> ; <br /> i <br /> I <br /> i <br /> ^ i <br /> b�'` I <br />