Laserfiche WebLink
Backwater Prevention Device <br /> �E Rebate Program <br /> Vendor Section (please print): <br /> .'7 -• � <br /> / f ) i <br /> �c�LLLC/, ( :�;.f-,-��F�V(-.il�'!'�i1��i . ��'___ _ /li! -�__.�_� �t1 / _ � i <br /> � - �. .-- <br /> Vendor Name J f3usincss Narne/U(31 Number <br /> : � <br /> _f �t-.r1,_ �'% ����� ��lc� <br /> Stale of Washing(on Coniraclor License Numhr.r <br /> 1��:j r���� �r..4 'rV�^_�/t.i��.-`'ic_��r�l�_�i;(Y- - --- --lL' l�J �/J— <br /> Vendor hdailing Address Cify Slalr. Zip <br /> NT'> -.:=� j'lr�'� —�"-��'�_�r„1?.nNcc�l'CtsU9rr'�tlro f-=«1'-✓�--- <br /> Phone [mail <br /> I, the Vendor, agree to receive the Backwaler Prevention Uevice rebate check direcUy <br /> for the installafion referenced at the Property Address By ayreeing to receive Ihc rebal^ <br /> check direcUy, i agree lo the (ollovriny: <br /> 1. The (3ackwater Prevention Devir.e rebale amount will Le deducled frorn Ihr, final <br /> invoice given to ihe Property Owner f,�r the ins�allalion a� Ihe Propeity A�Ir'rc.;; <br /> referenced �abovc, if Ihe total cosl of the mstallation is yreater Ihan lhe rel�;�t�: <br /> 2. I, lhe Vendor, ani a lNashinglon Slote licensed conlracinr. <br /> 3. ihe City of �veralt�vill send a Federal Fonn 109J W11SC lo �ne, Rie Vend�x, fur <br /> the Backwater PrevenGon Devicc rebate payments lotaliny more ihan W6UD per <br /> calendar year, and will report lhe sarne payments to ihe Internal Revenue <br /> Servir.c. <br /> I acr.ept tlie direc( payrnenl oi lhe Har.kwr��i�i Prr.ve�lion Device rebate from thi� Ci�y <br /> of Everelt pending approval o( the completed Bnckwatcr I'revenlion Devir.c� robate <br /> package hy thc City oi I_vcroQ <br /> /�'l!tl`�C��l �� �1�4���-� �z �/ 5 <br /> .Siqnalurc uf Crnili;icln� --- - ----�-- -. ..---- --- �):�Ii� l� <br /> Pnyc 2 u(? <br /> lZ�,visi't1 417�;Ul�f <br />