Laserfiche WebLink
n <br />Contractor Section: <br />/�Yoir� Piu,-, �, �9 --�3 p � � Qs� <br />� Vendor Name / Business Name ! UBI Number <br />�PG �� G% ---- - <br />State o( Washington Contractor License Number. � <br />�07 �j����Nf �'la/-�'S_V�//C _ v/_g —��7rJ <br />Vendor Maiiing Address City State Zip <br />I-�g7— /.S�% - — <br />Phone Email <br />I, the Vendor, agree lo receive lhe Backwaler PreventionfD'evice rebate check direclly for lhe � <br />instailalion at lhe above referenced property address. By agreeing to receive lhe rebate check <br />directly, I agree to Ihe foVowing: � <br />�e <br />1. The Backwater Prevention Device Pe"bate amount will be deducled from the final invoice � <br />given lo ihe property o�vner for ihe installalion at lhe property address re(erenced above, if <br />the total wsl of lhe installation is greater than the rebate. l� <br />2. I, the Vendor, am a Washington Slate licensed contraclor. <br />3. The City of Everett will send a Federal Form 1099 h41SC to me, the Vendor, tor Backwater <br />Prevention Device rebate paymenls lotaling more than 5600 per calendar y�a�, and will <br />report the same payments to ihe Inlemal Reveiwe Service. <br />I accept the paymen; o( lhe Backwater Prevenlion Device rebate (rom lhe City oF Everetl pending <br />approval of lhe completed Backwater Prevention Device rebale packac�e by the Cily of Everelt <br />0 <br />� I Signalure o( Contractor <br />� <br />3,/��is' <br />Date 1 ' <br />l,; <br />