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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Pleasa use ihis Invoice Cost Breakdown as a tempiate for invoices submitted as paA of the Backwater <br /> Prevention Device rebate proofam. Edher 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 billing templete while atiowing <br /> city sta(1 to Identity how costs eligible for ihe Backwater Prevention Device Rebate were accrued. <br /> Only la6or and maferials direeNy related to fhe insfallallon and/unetJon of a backwater prevenNon <br /> devlce a►e eliglble lo►Clty rebafe and there/oie should be included on the upper hall oi thls form. <br /> Additional cosfs may be added fo boffom of the/orm. <br /> t��'�'('r�� ��� <br /> Business Name:,�.��iu.�1�L�; �['�2 License Number: (7536`7cl <br /> Business Mailing Address: o�Gx-�o C.Gt I'�iVl _ �.!1�-. �(,l�?I"� L� �� ��i _ <br /> City State Zip <br /> Phone:��(o',�1�_�.� Email:(���nAwr���� 'c:t]i��l 5�[��bt',-r 2�!'. Cs�, <br /> Cate o Descri tlon Units Ouanti Rata Total <br /> Administration AdministraGon/mana ement Hours <br /> Labor CCTV lnspeclion Hours �_ _ �� <br /> gWV Install Hours <br /> Pipe re lacement Hours <br /> SurTece restoralion Hours <br /> – ___ ----- --- �ile cleanup _---- Hours <br /> __ __ _ - _._ ... <br /> Downspouts/drainage imp. Hr�rs � <br /> Materials Bnckwalervalve FerUnil � _�� � / <br /> Grinder pump Per Unit <br /> Slde sewer pipe(up to 8 feet) _ Feet ' �� <br /> Imported Backfill Yards <br /> Surface Resloretion Malerials Lump <br /> to soil rass seed,wncrete,etc. sum __ _ <br /> Cover(irrigation 6ox or load bearing Por Unit <br /> coverj____. _ � <br /> Rontals 5pecify equipment Flour <br /> __ i.�i��r�� --1- .��---��-. <br /> Fees Disposal fens by item __ Yards _ _ __ ���� "� <br /> Dr.livery fees il not cnvereA b labor _ <br /> EII Ible Total $ <br /> Olhcr Costs Costs not associated with BWD, and <br /> not eligible for rebatn delail below_ _ _ <br /> -- — lt_.T�__ W-�"7L�a, <br /> ---- � iL_ <br /> — �—�' ...e�l 1 <br /> Ineli ible Total s 10 � <br /> Total $ <br /> Ravised 9/03/2014 <br />