1127 GRAND AVE 2016-01-01 MF Import

i I ; ; ; � Contractor Section: � ---- /1'1 c�°,� l�l�„�,� �., � U � G �l�l `I�l,� i Vend��r Name I Business Name I U41 Numher � � Mven 1�� ` �f8 3.Jo ; State of Washington Conlractor License N:imber: i � �S � S �i i u s l s_r- 5��l��r-,�'sl�, �^'� `��a�i U � Vendor Mailing Address City State Zip ; '-1�5 76U 4s36c� i�e�f � noen �'1�„�la,'��ri , co� � Phone Email � L _— � � I,lhe Vendor, agree to receive the Back�vater Prevention Device rebate check directly for the � Installalfon at the above referenced property address. By agreeing to receive the rebate cheek directly, I agree to the following: i 1. The Backvrater Prevenlion Device rebate amount will be deducted irom the final invoice � given to the prooerty otivner for the installation at the property address referenced above, if ' the total cost of the installation is c�reater than the rebate. i 2. I, ihe Vendor,am�Washington State licensed contractor. 3. Th�City of Everett ti�ill send a Federal Form 1099 MISC to me, lhe Vendor,for Back��ater ; Prevention Device rebate payments totaling more than S6Q0 per calendar year, and�vill ; report the same paymenls to the Internal Revenue Service. j I I accept lhe payment of lhe Backwater Prevention Device rebate from the City o( Everett pending � approval of the completed Backwater Preventinn Device rebate packa�e dY ihe City oi Everett i 1 i ,/ 1 S� ' � °;l2e_:1 ''`� ��'�ze,�� c�� _ I b' — I Signalure of Contractor pate ' i � _- ; ; (I I