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BACKWATER PREVENTION PROGRAM <br /> � INVOICE COST BREAKDOWN <br /> Please use tnia lnvoice Cost Breakdown as a templale for invoices submitted as perl of the Backwater <br /> , Prevention Device rebate program. Either this form or your own invoice form wilh the�followinp line Items can <br /> be subrnitted. Ttiis allows you to invoice your clienl according to your oxisting billing l��mplato while allowinc� <br /> city stat(to identify how cosis eligibte for the Back�vater Prevention Dovico Rebafe were eccrued. <br /> Only labor and materials directty related to the lnstallatlan and/uncfion of a bacAwater preventfon <br /> devlce are eliglble lor Clty rebate and tl�erefore should be lncluded on the upper hall of thls form. <br /> Addifional cosls may be ndded to boffom of the lorm. <br /> ,,�,'� j,(,�.� / <br /> Business Name:��j,lreY_1_���-���S/LTcerise Nurt�ber:_���j�`'�� _ <br /> Business Mailinfl Address:o�/K-�O ._u�,_('��'�u�.'��'n'-� �-��A._—_7s�L�— <br /> City State Zip <br /> Phone:�;�a_'.�":�C?�'� Emai1:�L�lLVY�1S �� � 1�]l�,S;de.6r,-�C,!': CcSYl9 <br /> Cate o UeaeriPtion_ Units �uanti Rato _ Tolal <br /> Admihistration Auministrat(on I manag�mont Hours <br /> - -- <br /> —--- — __ <br /> Labor CCTV Inspeclion ___ Hours _�_____ �____ <br /> --- - yVW lnstall -- — Hours -- --- ---..---- <br /> pipQ replacement Hours __ _____ <br /> Surfoce rastor�lion — -- liours /_ �a[� <br /> � Sile cloanup __ Hours «_ _ _. <br /> Downspouts I druinaye imp ___ Hours n'� <br /> Materfals Backwoter vnlvn ____ Per Unll �' �-�_�j�lT _ p{ti� <br /> � Grindor pump Por Unit _ <br /> Slde sewer pipe1up_to R feet Feet �_ �� _aL(��. _.. <br /> _ _ <br /> --- <br /> ImportedBackfill ar s _ _ _ _ ___ _ __ ._, <br /> Surf�co Restora�ion M�lerials Lump 'l <br /> to soi�rass_seed,concroto,nic.)_ sum __�__ _ ._�(�_�.av__.__ � <br /> --- <br /> — — <br /> Cove�(irrigatinn box or Inad bnaring Por Unit ; <br /> cover�-- -- - -- - �- - - 1�-- -�� -- � <br /> - - --- _ . <br /> - - - Haur <br /> Rentais Specify equi ment _ _ __ -_.— -- -- - -- . ._ __ <br /> ---_ _ — <br /> - - - <br /> �/�GC.�._-�-- — _ _ _�_ __ ___?x3�_ _ a-. <br /> -- - -- --. _ — -- --- <br /> — --- — <br /> ------ — — — v,�d� <br /> Fees �--'� I)ispo�al frr.s by ilrm . — --- �.�- .-�. <br /> -- -'— <br /> ' -------- '-- - ' � - <br /> -_--__ _---. . - -- --- -'•- - -� -- <br /> I]elivery Ir.rts if not r.ovcr�kl 6y labor _ _ __ _ _ _ . . ___ . <br /> �--- -- --- � - -� - �- - - -- - �- <br /> EII IbleTotal- - - - ------- h $ <br /> Othur Coses Cos1s nul assoaated wdh BWD,and <br /> not eli ihlr,for rebalo(delail br.low)! __ . _ ___ __ ___� _ _ _ _--.. - <br /> _ _ . . _(Jk._1u_��N� r�.-, ra� Y�+i 1}� ci-. l,�i'17� <br /> - ---- - -- — - - - -� - — _ <br /> - --- -- - <br /> - - - -- - <br /> _ - - - _ _ -- - <br /> _.._ ___� . �.�� Gb <br /> _"" _- _ " �� . _ _. ._._ <br /> - _'__. . ._"-'_.'. " _ ._ _- � <br /> . .. "'_ ?lllla� �.v^r.t.11 . _ ..__ <br /> _'_._. _ _ __ — .. __—'_.__-____"-. ... .. ."_' _' <br /> _._ ' '_ _ .__��t� i�. . ___. .___ <br /> _ _ ..� .____ _ . . $ <br /> . .-_._.._ .. _. -. -_-__._.—__ .. <br /> IneNgible Total <br /> ToUI � _. 'u�- <br /> Rvvised 9/03/2014 <br />