Laserfiche WebLink
� <br /> Contractor Section: • <br /> ���ei i.S �1�CL�t�ih_ y �� ���^�^1�V� �Cq�-�8 z- �1 t3 � <br /> Vendor Name!Business Name/UBI Number � j <br /> �9�--{�1�1xo��PP <br /> State of Washinglon Conlraclor License Number: <br /> �(pCl ud��Ll-✓GtWt� 1 „'C� f�life� �' �d"�CJ <br /> Vendor Mailing llddress City Stale Zip <br /> E12� <1.�8�— cs123 �,9 /�I�wi h,v�� [.�c ��(°' C�.,v�r�.� Cw.� <br /> Phone Emad � <br /> ( <br /> I, the Vendor, agree to receive the Backwater Prevention Device rebate check direcUy (or lhe I <br /> insta;lalion at Ihe above referenced pwperty address. By agreeing lo receivc the rebate check I <br /> direclly, I agree to the following: <br /> 1 The Backwater Prevenlion Device rebate amount will be deducted (rom the final involce <br /> given lo Ihe property otivner for lhe installalion at the property address referenced above, if <br /> lhe tolal wst of the installalion is grealer than lhe rebate. <br /> 2. I, the Vendor, am a Washington Slale hcensed contraclor. <br /> 3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br /> Prevention Device robate paymenls totaGng more tha�5600 per calendar year, and will <br /> report the same payments lo lhe Internal Revenue Service. <br /> I accepl the payment of lhe Backwaler Prevention Device rebate from Ihe Cdy ol Everett pending <br /> approvai of Ihe compleled.Back�vater Prevention Device rebate package ty the Cily of Everett <br /> `��f '� �p—d�" �5 <br /> Signature o(Conlractor � Date <br />