1420 RUCKER AVE 2022-05-12 - Laserfiche WebLink

i 1 � I Contractor Section: � -- — ------ - , �Xi�'L.r,�� G-�i3 G/3 GSf1 ; Vendor Name/ Business Name I UBI Number ; �4 P�i //�G G�LT - State o(Washington Contractor License Number. ' -- -s y�7 7lJr A�e ni�� A,-y��iic wp �f�x i � Vendor Mailing Address Cily State Zip � I �/�.� 3�i7 �s�7 ; Phone Email � � � I, the Vendor, agree lo receive the Backwaler Prevention �evice rebale check directly for the � � installation at lhe above referenced property address. By agreeing to receive lhe rebate check i direc0y, I agree to the following: � 1. The Backwater Prevention D::vice rebate amount wiil be deducted from the final invoice � given to the property owner for the installation at the property address referenced above, if i lhe total cost ot the installation is greater lhan the rebale. i 2. I,the Vendor, am a Washinglon Stale licensed contractoc 3. The City of Everett will send a Federal Form 1099 MISC lo me, lhe Vendor,for Backwaler � Prevention Device rebate payments totaling more than 5600 per calendar year, and will repoA lhe same payments lo Ihe Inlemal Revenue Service. I accept the payment o(lhe Backwater Prevention Device rebale from the Ciry of Everell pending approval o(the completed Backwaler Prevenlion Device rebate package by tl�e City of Everett � + l�/��/�� SignaWre of Contractor Date 1 i --- I ' i i I . . _.. ._ _ . _ . .