Laserfiche WebLink
i <br /> Backwater P�-evention Device <br /> Rebate Program <br /> Vendo�r Section (please print): <br /> �� c � c�+ - <br /> �,�F�=u-�— -�.�,�� ���(�, -i—ti��—, �—(y U L 1 Zl�. 1 `�' <br /> Vendar Narr,c /Business Name I UBI Number � <br /> CAmP('�P :L c1�1 �1�`? <br /> S,ate of Washington Contr�ctor License Number: <br /> �L . t��ti `�S�-ll �v�c�:7i i,�r� �l��lc, <br /> Vendor�viailing �adress City State <br /> �t Z`_� - 2.5�( - 5`�'S`1 � � � Z�p <br /> � _ >�fbi(_C___/�jC��.1��1�1�5 � 1���'ath�rl4 � �u��� <br /> Phone Email —_�--� <br /> — � <br /> I, lhe Vendor, agree lo receive the Backwater Prevention Device rebate check d;rectly <br /> fcr Ihe installation referenced at the Property Address. Dy agreeing to receive the rebate <br /> check direcUy, i agree to the following: <br /> i. i'he Back�valer Prevention Device rebate amounl will he deducfed irom the final <br /> invoice given to the Property Owner for tlie installation at lhe Property Address <br /> re�erenced above, if the total cnst of the installation is greater than the rebate. <br /> ?. I, Ihe Ve.ndor, am � Washington State Iicensed contractor. <br /> ;? 1 he City o( Everett will send a Federal Form 1099 MISC to me, the Vendor, For <br /> the E3�ck�v,rier prevention Device rebale payments totaling more than 5600 per <br /> calendar year, and will report the same payments to the Internal Revenue <br /> SL'NICC. <br /> I accept the diroct payme;it nf the Backwater Prevention Device rebate irom the City <br /> nf Evere�tt pending approval oi the comple�ed Rack�vater Prevention Device rebale <br /> package by the._�i1�yf Everelt <br /> / � � <br /> ��_\ =` _ /-�l �/- /,�. � <br /> � � _ __ _1�7__3 /S <br /> �' <br /> Signt�fu/�(CJnfiuctor ----- — ------- - <br /> n�r� <br /> Rr.vi^r,d 9/3/�p1q Page 2 0(2 <br /> S� <br />