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BACKWATER PREVEfVTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use lhis Invoice Cost Breakdown as a template(or invoices submilted as part of the Backwater <br /> Prevention Device rebale program. Either this form or your own invoice form with the following line items can <br /> be submitted. This allows you to invoice your client according to your existing billinc template wh�le allowing <br /> city staff to idontify how costs eligible for the Backwater Prevention Device Rebate�vere accrued. <br /> Only labor and materlals directly related to the lnstal/aHon and luncf(on o/e backwater provention <br /> devlce are eliglble for CIty rebate and fherefore should be/ncluded on the uppe►hall ol thls form. <br /> Additional costs may be added fo 6ottom o(fhe Iorm. <br /> 5�;c�t'r,�'�'�'' d <br /> Busfness Name:�-�(r3�����P License Numbcr:�Sy�i.���•� _ <br /> Business Mailing Address: bZ�: �.Cc/'�1 11JE---4-��n'� LL�A 9�'.�tl�i <br /> City State Zip <br /> Phone:�;.�fc� ~,'�1�=L Email:�,i�ri�r���n.�� c-r;fld S.�d.�1,�c���p�- C'c%�� <br /> Cate o Deserl tlon Untts �uanti Rete Total <br /> Administrallon Administralion!managemenl Hours <br /> Labor CCTV Ins ection Hours � _ <br /> 8WV Instalt Hours <br /> Pipe replacement Hours __ <br /> SuAnce restoration Haurs '— <br /> Sito cleanup Hours <br /> Downspouts/drainape imp Hour� <br /> Matorials Backwater valve Per Unil ���y �f15 <br /> Grinder pump Per Unit <br /> Sido sewer pipe(up to 8 feet Feet " a <br /> Imported Backfill Yards _` ___ <br /> Surface Restoralion Materials Lump <br /> to sod rass seed, concrele.,etC. sum D ��_ <br /> Covor(irrigation box or load bcaring Per Unit a <br /> cover ____ _1.-- <br /> Rentals Specifyequipmenl _ Hou� _ _ ____ ___ _ <br /> -- --- — �� _ � _ — 3�- <br /> Focs Disposal(�es�em __ _ Yards _ <br /> ------ - --J�va- <br /> Delivei fecs if nat covereA hy labor __ __._—___ <br /> EII ible Total - ---- ---- -^- — S <br /> Other Coses Cosis not associated with BWD, and <br /> not eligibie for rebate(defail below ___ _ __ <br /> -------- ---- — -U_4�r2-it_ u.�aclw .�4�4:4'C <br /> -- — .wi..t <br /> IneligibleTotnl $ �����1�( <br /> Total _ � 3 =5 <br /> Revised 9/03/2014 <br />