1411 36TH ST 2018-01-22 - Laserfiche WebLink

i r- �ackwa�fer Prevenfiion Device E� � Rebate Program = Vendar Section (please print): ._ __---- -____. . ... -----______ __..._ ----__ _.. � _, - , _ ' � J �� ;'i'Y �l'� `�rUs i iU�;i i I Gi� �:�'�'� `-_"� �f,'G? �.� G v_`l ....�_`�'_, - -- � �.------ - - = - - Vendor Nam� / l3usiness Nan��/ L1B1 Nurnbcr �7 - � – �, iC%�'!cC- :.� ��f�,`� i�lf.A-, State of Wasl�ii�gion Contractor Licens� Nuinbc�r: ��.) i� �' 1/ , - , i - .. � ,.. � ,r� i-�>/7� ��-) J� � 1� ` �,:`�r '�,�,` G�'��{: �<<-v�-�� ,� � __ _ ------ ----- ----- -�_____..--=--- Vendor Mailir�g Address City Sta(e z�p M.. ;.��, �. ; 1 ,• _ , - . ; -- '- � . � �� .7�='�- 7 �r�.l �I i-�.y v�"°� �/''�C>�'��',�l�'r'F��-'�•f (L`�� [.�(.'�:•,/\ __.-------- ------ �. /�---------------�- -�--------- f'hone Email I, the Vendor, agree to receive the Backwater Prevention Device rebafie clieck directly for the insta!lafion referenced at the Properky Address. By agreeing to receive tf�e rehate checfc directly, I agree to the following: 1. The Backwater Prevention Device rebate amounf will be c��duc#ed frorn tf�e final invoice given to fhe Property �wner for the installaiion at fhe Property Address referenced above, if khe tofial cost of the i��stallation is greater than the rebate. 2. i, the Vendor, am a Washington State licer�sed contractor. ;� 3. The City of Ev�rett wiil send a Federal Form 1099 MlSC to me, the Vendor, for the Backwater Prevention Device rebate paymer�fs toialing more tl�ar� $600 per calendar year, and wiff report the same payments to the Internal Revenue Service. I accept the direct payment of the Backwater Preveniion Device rebate frorn the Ci#y of Everett pending approval of fhe completed Backwater Preventian Device rebate package by tl�� City of Evc;rett �� , ,� J.� �' �r --_' ,��.,� ; - �. . C� �..��. ignatc�r-e of Cnrlfracior —�._ Dalr� —.---- Page 'L of 2 Rr�viscc� S3/3%1_01�E ;