Laserfiche WebLink
i <br /> BackHrater Prevention Device � <br /> � Rebate Program i <br /> � ; <br /> � <br /> Vendor Section (please print): ! <br /> �-- ------ — --- i <br /> � I_�{�x,, PL�...-, �1�,.,.. �� C (v c�1 _�z_, - n I U � � <br /> I Vendor Name I Business Name/ UBI Numbm i <br /> ��nc�('F'LR(��3^�+ ----- -- --- I � <br /> State of Washinyton ConUactor License Number. I <br /> IPl?(�h,� �t�-� sNuy�„�.,�ia c,,.�ti. �j�'7_9, ; <br /> Vendor Malling Address City State Zip <br /> I � _ � <br /> 7DfJ_ • Q�(.� -()%'7_ � _ f�?,�/-CulIIr. S !� V,.t,'/,7�� . <<�.c� <br /> Phono Email ��� <br /> I <br /> - — — I <br /> 1, the Vendor, agree to receive the Backwater Prevention Device reb.,te check air�ctly i <br /> lo� the installation referenced at ihe Property AdAress. 8y agreeing to receive the rebale ' <br /> check directly, 1 agree to the tollowing: <br /> 1. The Backwater Prevention Device rebate amount will be deducted from thr. final <br /> invoice given to lhe Property Owner for the installation at lhe Property Address � <br /> referenced above, if the tolal cost of the installation is greater than the rebate <br /> 2. I, the Vendor, am a Washington State licensed contractor. <br /> 3. The City ot Everett will send a Federal Form 1099 MISC to me, the Vendor, for � <br /> ihe Backwaler Prevenlion Device rebate payments totaling more than $600 per ; <br /> calendar year, and will report the same payments to the Internal Revernie i <br /> Service. ; <br /> I accept the diroct payment of the Backwater Prevention Device rehate from the City � <br /> of Everett pending approval of the completed 8ackwater Prevention Device rebale � <br /> package by the City of EvereH � <br /> = --- - -- - �Z=-��_ �r-- : <br /> Signnlure of Contracfor Dale , <br /> I <br /> � <br /> ! <br /> Page 2 012 <br /> Rev�sed 9/3l2014 <br /> � <br />