3527 LOMBARD AVE 2022-05-02 - Laserfiche WebLink

; � P�' Backwafer Prevention Device �� n Rebate Program Vendor Section (please print): �._ � � _ /,. � �) i � �,' � - ��>��7 IZ�C-!l c-�.l T/�.��L , ;`_-°� � f ? i f ? (L I � l� � �c.�I V C_�-z � �-i ____..—� _-_ _._._ _ _-------- ; Vendor Name/ Business Nan�e / U81 N�uliber � � , , ,, �i t;'��c;(.`7 ��5`.� i Ll l.�-= ` __._-- — _ ...._ .._. State of Washington Contractar Licensc Number. `��)� C� �i� � - � _� , i� � �,^S,'-_ �� � _ � 1 �t��'��---��-�r. 1rr.-i,r_�%iV5 U��;�y l_.J .� - ---- - --___ _ /,�__._—----� Vendor Mailing Address City State lip ��Z'j-_`j.`�%- ��%_7� `' ;,;� � � ,1. ,, -- - ��r �---�� l t��__�_�C?�''`� _ � C r Jf/�t c �/�>, . t t'� = — --�- — �:. Phone Eir�ail ��. l, the Vendor, agree to receive the Backwater Prevention Device rebate cf�eck directly for the installation referenced at the Property Address. By agreeing to receive the rebate � check directly, I agree to the following: �; i� �. The Backwater Prevention Device rebate amount will be deducted from the final invoice given to the Property Owner for the installation at thE Property Addres� referenced above, if the total cost of tfie installation is yreater than the rebate. 2. 1, �he Vendor, am a Washington State licensed �onkractor. ; 3. The City of�verett wtll send a Federal Form 1099 MISC to me, thc Vendor, for the Backwater Preventian Device rebate payments totaling more t1�an $G00 per calendar year, and will report the same payments to the Infernal Revenue � ; Service. ; I accept the direct payment of the Backwater Prevention Device rebate frorn the City of Everett pending approval of the comp(eted Backwater Prevention Device rebafe package by the City af Everett � � ;1 � "' _i �'•:; � ��, ��-`�-.�_ 9 l' �- ��r �� �____ rynatule of Coi7tractor Ur1lf° f�c7c� 2 c>f 2 Rc�visc�cl 9/3/101��