1701 LOMBARD AVE 2017-01-13 - Laserfiche WebLink

Contractor Section: /� r ` � � t�Lt.c. �+'I l�ZL ._..rt,/c.� (�.� ~- �% � � � S � Vendor Name I Business Name I UBI Number ,�r�� 'i ,�'G �� Staie of Washington Contractor Licei�se iV��mber: ..�'��7 �7�� -�� N� ��12 S�S uLI�L�= ,�v/� y�',y�, �� Vendnr Mailing Address City State Zip � %� 1 S� � �S' � ''�� Phone ` Email --._._...._.. I, the Vendar, agree io receive the Backwater Prevention Device rebate checEc directly for the installation at the abave referenced property address. By agr�eing to receive the rebate check directly, 1 agree to the follo�ving: 1, The Backwater Preverttion Device rebaie amount �vill be deducted r'rom the final invoice given to the praperty owner for the insta�lation at the property address referenced above, ir the totaf cost of ihe installation is greater thar the rebate. 2. i, fihe Vendor, am a Washington State licensed contractor. 3. The City of Evereft will senci a Federal Form 1099 MISC to me, the Vendor, for Backwater Prevention Qevice rebate payments totaling more than �600 per cal�ndar year, and wilf rsport the same paymants to the internal Revenue Service. I accept the payment of the Backwater Preveniion Device rebate fram tE�e City o1 Everett pending approval of the comp}eted Backvrater Prevention Device rebafe package by the Ciiy of Everett Signature of Contractor � -c.� --t� Date