1701 RUCKER AVE 2022-05-12 - Laserfiche WebLink

i I i Contractor Section: � �iCtl!-'11—`�t:�� N. � � c, +LL�>_c.�?� :3C�i-d,3 � Vendor Name I Busine s Name I UGI Number i i /�- 1��fa-�-��- Il r' � fa� ---- 1 � State of Washinyton Contractor�icens;e Number: ' �� L.a.r l��, "�t�'�r��t�" L[.7�4__�'�%. o"`_ I Vendor Mailmg Address City State Zip � r � a(�,-�-fC�-c?t7�1'a C�[I'k7l f i (A�� . c�-,.._�GC11D��C�/1/� ' Phone Email � 1 i � I, Ihe Vendor,agree to receive the Backwaler Prevenlion Device rebate check direclty for lhe ` installalicn at ihe a6ove referenced property address.By agreeing to receive the rebate check j directly, I agree to the following: 1. The Backv�ater Prevention Device rebate amount will be deducted from the final invoice given to the property owner for the inslallation at Ihe property address referenced above, i( ; the tolal cost of the installation is greater than Ihe rehate. • 2. I, the Vendor, am a VVashington State licensed contractor. � 3. The City of Everett will send a Federal Form 1D99 MISC to mc, Ihe Vendor, for Backwater i Prevontion Device rebate payments totaling more than $600 per calendar year, and will report the same payments lo the Internal Revenue Service. i --- --- �— — — � I accepl lhe paymenl of the Back�vater Prevention Device rebate froin thc City of Everetl pending approval ot lhe compleled Iiackvdater Prevenlion Devir.e rebate package by lhe Cily o� Everell . i / �//� �/�}� I�( II l , t/a/c'(�Aj- �- ._:�a+-'�=-�«-- . _ _1_L_Ll�(�__._ � Signalure of Contractor Date ; � i -- — — — ; i j � i � I