Laserfiche WebLink
{ <br /> i <br /> Contractor Section: <br /> ; <br /> �lven I� I �—,� l>—>�—�� � LG C,-.63 - �1�3 - F�`� <br /> Vendor Name/Business Nama%!�BI Number <br /> �`'1Uc'_r PP'-I` SSSS .) i> _ <br /> Slate of Washington Contractor License Number: <br /> I 7 5 I S �-1 I`� fJ Sf; 5n�h u,,.��c�� �✓II �=t�Z.`t u � <br /> Vendor Mailing Address Ciry State Zip <br /> �� i <br /> �i��" ��u ���� � , �„� �� ti���.���u,�,r,;,zy .`�,� <br /> Phonc� [mail 'j-- --- <br /> I, the Vendor,agree to rc :eive the t3ackwater Prevenlion Device rebale check direr,tly for thc� ` <br /> in,tallalion al Ihe above i�ferenced property address. By agreeinc�lo receive ihe rebate check � <br /> directty, I agree�o the follc,ving: ' <br /> 1. The Backwater Prevention Device rebale amount�vill be deduc!ed from lhe f nal invoice <br /> given lo Ihe property o�vner for the insfall�tion ai the properiy address referenced above,if <br /> Ihe folal cosl of Ihe inslallation is greater than Uic rebate. <br /> 2. I, the Vendor,am a Washington Slale licensed conlraclor. � <br /> 3. lhc Cily of Evereli will send a Federal 1=orm 1 Q99 MISC !o me,thr.Vendor, for 3ackwater <br /> Prevenlion Device rebate payments lolaling more than 5600 prr calendar year, and will <br /> reporl Ihe samc paymenis fo the Infem�l Revenue Scrvice. <br /> � <br /> I aiz:r.pt Ihe payment of the Backwater Prevention Device rebate from the City o(f_verett pending , <br /> approvnl n(lhn r.ompleled �nckwaler Provention Dr.vice rebate packa9e by the Gty of tverelt � <br /> ��� �� �- .�U —t J' . <br /> Sign:�fure of Conlraciur Date ' <br /> i <br /> I-- — — — —._ — . . — — — --- - <br /> % <br /> � <br /> � <br /> i <br />