1505 ROCKEFELLER AVE 2022-05-11 - Laserfiche WebLink

i ; ; Cnntractor Section: . � � _ � � �, , i f�l��i�--`� ' �'�1�. ��'�L�,_LLG (��c>�3 Z�:3 I Vendor Name I Ciusine s Name 1 UBI Number i _�Ll-��T��-�—K'�f,,.. ' � State of Washington Contraclor License Number: i ��—LcsrJ,i►1—Q_1�,,_—_1��.t-��.`�� >� � 'Jendor Mailing Address City Slate Zip i a��c?-,�s,�C��r_�ds.c��.��_ << � ;l��rr� j Phone Email � , i I, the Vendor, agree to receive ihe Backwater Prevenlion Device rebale check dire�tly for the i installation at the above referenced property address. By ag�eeing to receive the rebate check i directly, I agree to the following: • 1. The 8ackwater Prevenlion Device rebate amount will be deducled from the tinal invoice ' given lo iho property owner(or lhe installaiicn at lhe property address referenced above, if the lotal cosl of the installation is �reater than the re6ate. � 2, I, the Vendor, am a Washinglon State Iir,ensed contrar.tor. � 3. The City of Fverett will send a Federal Form 1099 MISC to me, the Vendor,for Bar.kwater i Prevention �evice rebale payments lotaling more than 5600 per c;alendar year, and will i report the same paymenls lo lhe Intemal Revenue Service. i ---�--�'--- �---� --- ------- � -- � -- i . . ---�----- _-.._---- i I accept lhe paymenl of the [3ackwaler Prevention Device rebale from the City nf Fva�retl prandin� .piproval ot Ihe completed Backwater Prevenlion Device rebate package bY lhe Ciry of Lveretl i 1 ! I � •.��" �_?L� - -___--- �I�C>��_ '_.__. � Siynature o(Contractor Dale � — - - _ _ .__ _ _ ' --- -- - - -- - i I � �