Laserfiche WebLink
Contractor Sectiun: <br />�;U �1 � Y17� � 4%(�I '� , I�1�-,� � Vvv1 <br />Vendor Name / Business tJame / UBI Number <br />��-�1�� f-�'m/�'`� <br />State of Washington Contractor License Nurnber. <br />Vendor Mailing Addrp� s <br />2�=l��'�-o�z�� <br />Phone <br />�l� -�d2T (.�-'�`9 �J�- o �' <br />City State Zip <br />r� �l N-� L� r��l a �� <�y Z'' C-m � I <br />Email <br />... . _...�- ..e: i.. :� ...�...... .. � ..........:..i � �, t:���t��n ikvice rebate check dirediy for the <br />installation at Ihe above referenced�propeRy address. By agreeing M receive the rebate checic <br />direcUy, I�gree to the following: <br />1. The Backwater PreveMion Device rehate amount �vll ta: dbUu...�r nvul U W Illlul II IY V Wt. <br />given to the property owner for the installation at the property address referenced above, H <br />the total cost of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington State licensed contrctor. <br />3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br />Prevention Device rebate payments tataling more than $600 per calendar year, and vrill <br />repoR �he same payments to the Intemal Revenue Service. <br />I accept 1he paymenl of the Backwater Prevention Device robate from the City of Everett pending <br />approval of the completed BacMvater Prevention Devioe rebate package by the City ot Everett <br />; ;'� ()r`i - �L-1 S <br />Signa ure of Contrador DatQ <br />