Laserfiche WebLink
_ <br /> I <br /> I <br /> I <br /> � �ontractor Section: <br /> I <br /> � - - <br /> ! _�c.�� �1� � • u►��J��L—�Z�l_Z—'1 g <br /> � Vendor Name/Business Name/U I Number C� <br /> � _ _��p_l��l� __ <br /> � State of Washinglon Contractor License Number. <br /> � _��L__ vl S�fant.rv�_ I� �vrz:�- c�,� 9YZvE <br /> Vendor Mailing Address City State Zip <br /> �zs_`-1�39—o�Z 3 _ �4 Q��mhtnq (Lc d-+�F�CCrnn;( � <br /> Phone Email <br /> i <br /> � — — <br /> I <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly for lhe <br /> � installation at the above referenced property address. By agreeing to receive the rebate check <br /> � direcUy, I agree to the tollowing: <br /> 1. The Backwater Prevernion Device rebate amount wili be deducted from the final invoice <br /> given lo the property owner for the installation at the property address referenced above, if <br /> the totai tosi oi the installation is greater than the rebate. <br /> 2. I,the Vendor, am a Washington State Iicensed contraclor. <br /> 3. The Cily of Everett will send a Federal Form 1099 MISC lo me, lhe Vendor, for Backwater <br /> Prevention Device rebate payments tolaling mnre than$600 per calendar year, and wiil <br /> report the same paymenls to lhe Internal Revenue Service. <br /> I <br /> I accept lhe payment of the Back�vater Prevention Device rebale irom lhe City o/Everelt pending <br /> approval o(lhe completed Backwater Prevention Device rebale package by the City ol Everett <br /> .�r ��'' ° � 3-- y/� <br /> SignaWre of Contraclor Dale <br /> I <br /> I <br /> , , <br />