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Town of Wickenburg
Commercial Fagade Grant Application
Organization Name: \Vielole Developme’, Lue
Address: Ao w Wink Lay LdsZbvbne ,At B55
Phone: Y 80-958 -| BU 2" Phone:
Email: To. QofRL (A GAZL. Com
Contact Name and Title: Tons Qo, Menager
Scope of Work:
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Funding Amount Requested: 4 19, Ooo.
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Authorized Agency Representative Title Date
Demo Existing Facade and Entry Way = $3,500
New Doors and Entry Way = $11,000
New Framing for Patio and Entry Way (includes concrete extension for patio and metal roof
detail) = $24,000
Electrical Clean-Up, additions, and New Lighting = $4,000
Stucco = $16,000
Paint = $11,500
Re-Coat Foam Roof, New Capping = $6,500
Parking Lot Paving, Striping, Bollards = $30,000
New Sewer Tie in and Code Compliant Abandonment of Septic = $9,000
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Form Ww 9 Request for Taxpayer Give Form to the
. 5 2 . . requester. Do not
Department of herhosay Identification Number and Certification send to the IRS.
intemal! Revenue Service
1 Name (as shown on your income tax return). Name is required on this line; do nat leave this fine blank.
Viable Development LLC
2 Business nameydisregarded entity name, if different from above
6 City, state, and ZIP code
Wickenburg AZ 95358
7 Ust account number(s) here (optional
rv]
a
=
2 | 3 Check appropriate box for federal tax classification; chack only one of the following seven boxes. bm Exemptions (codes Ae only to
Nes, 3
8 1 tndividuavsote Proprietor or 3 c Corporation Oo S Corporation [J Partnership O) trusvestate instructions on page 3):
2 single-member LLC Exempt payee code (if any)
g BS] Limited liability company. Enter the tax classification (C=C corporation. S=S corporation, P=partnership) > s
3 — , 7
5 | Note. Fora single-member LLC that is disregarded, do not check LLC; check the appropriate box in the ling above for | Exemption from FATCA reporting
£3 the tax classification of the single-member owner. code (if any)
—__
< 5 Dotter (see instructions) » tAppkes to accounts maintained outside the US}
5 5 Address (number, street, and apt. or suite no.) Requester's name and address {optional}
&.| PO Box 3217
7)
Part) i Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given online 1 to avoid _| Social security number |
backup withholding. For individuais, this is generally your social security number {SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part ? instructions on page 3. For other - -
entities, it is your employer identification number {EIN). If you do not have a number, see How to geta
TIN on page 3. or
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for [Employer identification number )
guidelines on whose number to enter. [_T
4)7) -|2])0}2]5]/o0}2/14
EE Certification - _
Under penaities of perjury, f Certify that:
1. The number shown on this form is my correct taxpayer identification number (or 1am waiting for a number to be issued to me}; and
2. lam not subject to backup withholding because: {a}! am exempt from backup withhoiding, or (6) [ have not been notified by the Internal Revenue
Service (IRS) that | am subject to backup withholding as a result of a failure to report all interest or dividends, or {c) the IRS has notified me that 1 am
No longer subject to backup withholding; and
3. lam aU.S. citizen or other U.S, person (defined below): and
4. The FATCA code(s) entered on this form {if any) indicating that [am exempt from FATCA reporting is correct.
Certification instructions. You must Cross out item 2 above if you have been notified by the IRS that you are Currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For reai estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must Provide your correct TIN. See the
instructions on page 3.
&
Here Ue poner (Raa oate> (14115
General Instructions * Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098.7
(tuition)
Section references are to the Interna! Revenue Code untess otherwise noted. * Form 1099-C (canceled debt)
Future developments. Information about developments affecting Form W-9 {such
Fe “A iti band: f
as legislation enacted after we release It} Is at www.irs.gov/fw9. * Form 1089-A (acquisition or al onment ol secured property)
Use Form W-8 only if you are a U.S. person (including a resident alien), to
Purpose of Form Provide your correct TIN,
An individual or entity (Form W-9 requester) who is required to file an information #f you do not retum Form W-9 to the requester with a TIN, you might be subject
ratum with the IRS must obtain your correct taxpayer identification number {71 IN) fo backup withholoing. See What is backup withholding? on page 2
which may be your social security number (SSN), individual taxpayer identification By signing the filied-out form, you:
umber (TIN), adoption taxpayer identification number {ATIN), or employer
identification number (EIN), to report on an information return the amount paid to |. Certify that the TIN you are giving Is correct (or you are waiting for a number
You, or other amount reportable on an information retum. Examples of information tobe issued), . ,
retums include, but are not limited to, the following: 2. Certify that you are not subject to backup withholding, or
* Form 1099-INT {interest eared or paid) 3. Claim exemption from backup withholding if you are a U.S. exempt payse. If
applicable, you are also certifying that as a U.S. person, your allocable share of
* Form 1089-DIV (dividends, including those from stocks or mutual funds) any partnership income from a U.S. trade or business Is not subject to the
* Form 1089-MISC (various types of income, prizes, awards, or gross Proceeds) withholding tax on foreign pariners' share of effectively connected income, and
* Form 1089-B (stock or mutual fund sales and certain other transactions by 4. Certify that FATCA code(s) entered an this fom (if any) indicating that you are
brokers) exempt from the FATCA feporting. is correct See What is FATCA Feporting? on
* Form 1089-S (proceeds from real estate transactions) Page 2 for further information.
° Form 1099-K (merchant card and third party network transactions)
Cat. No. 10231x Form W-9 Rev 19-9n1a,
TOWN OF WICKENBURG, ARIZONA
155 North Tegner Strect, Suite A - Wickenburg, AZ 85390 MUST BE |
(928) 684-5451 / Phoenix (602) 506-1622 / FAX: (602) 506-1580 DISPLAYED IN A
CONSPICUOUS |
BUSINESS LICENSE: # 7149 PLACE
NON-TRANSFERABLE
‘This Permit cannot be transferred from one person to another. Notify the Town Clerk if business is discontinued, 1f there is a
change in the name of the business, a change in trade name, change of location, change i in mailing addcess or change in ownership.
‘The below is ‘by pe conduct business in the name of t
BUSINESS LOCATION: — 784 W. Wickenburg Way
RIGINATION DATE: — 11/22/2017
2025 LICE °
5 NSE EXPIRATION DATE: 12/31/2025
TYPE OF PERMIT: Annual
ISSUED TO: "TAZ, LC TACENSE DeSCRIPTJON: “Standard Licdnse
OWNER: = Qorti, Driton ; 7 “sf
MAILTO: 7121 EE. Rancho Vista Dr. #3006
Scottsdale AZ. 85251 Pamela Black, Senior Financial Services Specialist