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BACKWATER PREVENTION PROGRAM <br /> �' INVOICE COST BREAKDOWN <br /> Please use ihis Invoico Cost Breakdown as a lemplate for invoices submilled 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 cliQnt accord�ng to your existiny billing template while allowing <br /> city staff to identify how costs elic�,ble for the Backwaler Prevention Device Rebale were accrued. <br /> Only/abor and materials directly relnted to the installation and lunction o(a backwater prevenfion <br /> device are eligible�oi Clry rebafe and there(ore sfiould be included on the upper half of thls form. <br /> Additional custs may bn added fo hottom of fhe /onn. <br /> , 5�.�c�'C-',L�-�' . � <br /> 8usiness Name:�j'INri i..+r � C. � License Number: __,('-j�����",�___ <br /> E3usiness Mailing Address i�(c:t-(G LF��'��/�1 C 1l�-�_____1�(fl'�' ,�___(. �A O�l]=3 <br /> City Stale Zip <br /> Phone: ' <br /> .�'.�c�p_r,��,.� Email: � o�r�h1�/'r�c�4 � � 3ol1-�SiC{CSE'yr?"I'. CY�j <br /> Calogory ___ Description � Unfts �uanti Rate Total __ <br /> Administrelion Adminisirationlmanagemenl Hours _ <br /> Labor CCTV Inspection _ Hours _�___��__ <br /> gWV Install � Hours <br /> Pipe replacement Hours <br /> Suriacerestoration Hours _ ��_ <br /> Sile cicanup Hours __ _ <br /> �� Downspouts/dramage imp Hours <br /> Matcrials Backwater valve Per Unit }�..��1� ����� <br /> �J <br /> Grinder pump Per Unit <br /> Side sewer pipe(up to 81eet) Feel ��-(2�� � <br /> -- -- <br /> �mported BackGlt Yards <br /> -- -- - — -- -- ---- -_ - -- ---- <br /> Surfate Resloralion tJlaterials Lump <br /> _- - <br /> jtop soil�gras_s see_d concrgte etc. _ sum L_ �c7 c3 C� <br /> Covei(irriga�ion box or load bearmg Per Unil <br /> - - - <br /> cove1---- ---- --- -_-�a- -- ---La---- . <br /> Rentals Speci(y equipment Hour <br /> - - -- -- - -— -- --- - _- <br /> -----r�� --�-_ _ — -- - - —�--- —�� --s�._f?— - <br /> — — --- --- — --- ----- <br /> Fees Dis asal (e�a by ilrm Yards <br /> -� ---- -- --'- ---� �- -- — - ---- - .. _-- <br /> - �------ Delivery fer.s if not covered bY labor -- � — - � -- ---.. __.— <br /> ..-- __ - — . ..—._.___- �- --. _ _ . .---. . . <br /> EII ibleTolal , (}� $ <br /> Other Costs Costs not associated wilh BWD, and <br /> not el�ci ihle for rehatc {de�ail below) _ <br /> I— --- .. _---- - _ . _---- — - ---- <br /> . --- - --- - - -- _ ._ _-- - ---- <br /> ---- --- <br /> O�c � n_ S�„ «1zr <br /> — ---- — _-- ---- _- -_.-- -- - -- <br /> �l� y � y -- — <br /> -- ----- -- {'�� -�----- <br /> ___I-�-'i!1 N. �- _ �"__' <br /> Ine�igibleTotal - - --- -- - - - � - 5 I�����+�a�� /l/�i <br /> Total $ <br /> Revised 9/03/2014 <br />