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BACKWATER PREVENTION PROGRAM <br /> � INVOICE COST BREAKDOWN <br /> Ploaso use this Invoice Co,t BreaM.down as a template for invoices submittod as part of the B�ckwate <br /> Prevention Device rebate program. Either lhis lorm or your o�•m invoice form v+dh the following line ite�i: can <br /> be submitted. This allov�s you to invoice your client a:cording to your exisling b'ling template while allnving <br /> ciry staf+ to idenufy how costs eligible (or the Bar,k�va'Ar Prevention Devir.e Rebate were accrued <br /> Only labor and materials direc!!y related to the in.�taliafion and/unction of a 6ackwater pievenfion <br /> device are eligfble for City rebate and theretore sliould be included on the upper hall of this form. <br /> Addi6onol cos�s may be added!o bottom o/the lorm. � �� L�`J <br /> Business tJame:�y�[���czlZ �G'_I�iL'{r..`��C�E^�,Li ensc Numbcr ._����t"2j� _ . _.-_-- <br /> �� �� y� C r ` � �'Y�i <br /> f3usiness Mading Address: v��!G.:_. I..l�l.�_. �_ � 1-�I�i��- --- S A—L Zi ^�- <br /> City P <br /> Phone:.�7(o'v�LQ..� t` `-�_ -.--- [mail:� <'� 1!}LfiCu/l�'�i4LU�l�S.ciCSr�.�C°�^.Cs.>7]7 <br /> -- - Units Quantf Rate Total <br /> Category __ D¢seriPtfon _ _ _ __ �Y --� <br /> Administration AAministral�un/mandycmenl Ho�rs _ . <br /> _ -- <br /> -- --- - <br /> - -- - <br /> - - - � �- --- . -� �.b`i� <br /> Labar _ CCTVlnspedion _ - __ Hour ---� _ __�"'j]_ --- � <br /> �-- - --- -- BV✓V Inslall Hours - -- - - -_ .-- _ . <br /> - - - Hours ` <br /> Pipereplacement _ - -_--- ---- - <br /> -- - - — - -- <br /> -- - -- - � ,f/ <br /> Surface resluraGon Hou�s 1 <br /> ---- - --- - . ._ _- � - -�cJt+� --- <br /> Sde clea�up Nours <br /> - -- Do�ronsPouts/draina9e imp. — - -Hours-- -�-�-- -_�- � -�---�- � - .-- <br /> Materlals Backwater valve _ ----_ Pr.r Unil `3'���u-� -"-�k-- ��_ <br /> ---- - --- - Gnnderpump- -- ---� PerUnd __ -_ -- <br /> -- — Fc�t - -r- - � <br /> -- _ ------- _ - <br /> S�de sevier Pipe(up to 81eet) - - - - . _--_ - - �{"(p- -1 -- <br /> ------ - �mported Backfill Yards- - - I -- - - - --- - -- - <br /> � � Sur��r.c Resloration bt�lrrinl, Lump T � <br /> (top_so_,i_grass seed eoncr�te,etc.) _ sum __�__._ _ } _ _ .J� _ _ <br /> -- — ' <br /> -- - __ I <br /> Cover(uri9nhon hor or Inad br.�nng P�r Unit <br /> cover) -- - . .-� - - �-`�- - �a__ J <br /> Rentals S ecif e� ui ment Hour � <br /> --P--y--� P-- - -- - - - - - - - - -- ---_ _- ; <br /> ----.__ - - - ' <br /> m r�_-rr�.r F�r_ _ - - - L - - 3� - . _. � - <br /> -- - - -- - - - <br /> --- - - -— <br /> - - -- - - --- <br /> Fceti Dispo�al fF�:by dnm Va�ds <br /> - -- _ - ��a� <br /> -- - _- - - - - -- - - - - - -- — - <br /> - . - . .-... Delivery tees d not r.overed by I.ibor . -- __.. . . .- -- <br /> Eli fble Total- - - -- -, 7 - i- . - — - - $-- - - <br /> Othor Costs Cusls nol�issucia�ed with BWD, and <br /> _ not eUyiblc lor rebate{detail below) _ __ _ .—._ <br /> ..-- — � -- �-- - - -- . ._ . _. . . — <br /> - - - - - -- --�� - �� p_�- C ���- �-�- -- -- --_ - <br /> -- - - - -- - - - - <br /> — -_- - _= =_#�,-�o J�- �T= - `�-�� - ___ __-_ - - <br /> --- -- <br /> -- -__— - -- - -�n,-,� o� - � - - <br /> rineligible Total <br /> Lotal -- -- - -- ^— $_ 3�r E{ <br /> — — --- — - — <br /> �rr��__ � <br /> � /`� /IS <br /> Revised 9/03/2014 <br />