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BACKWATER PREVENTION PROGRAM <br /> ItiVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown a�a template for invoices submitted as part of the Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form wdh Ihe foilowing hne items can <br /> be submitted. This allows you to invoice your c:ienl according lo your existing billing template while allowing <br /> city staH lo identdy how cosls elic�ible for the Backwater Prevention Device Rebale v�ere accru�d. <br /> Only labor and materials directly relafed to the installafion and function of a b e�1(o�hls lo�mn <br /> device are eligible for Ciry rebate and therefore should be included on the upp <br /> Additional costs may bo added to bottom ol the (orm. <br /> 5t'�lY'�.u"c' /' <br /> Business Name:��1��j(�.t'1 � � ��iL`�e License Number. __���'�:1_��__ _ _._._— ._ <br /> 6usinessMailingAddress: oZ�o LGcrI�(�1 �/��-• �(�11—�� ������� <br /> City State Zip <br /> Phone:,�-�a_.'�C�__ra�12��.i� Email:�,i �l 1�csn � � !�-��:��'C_�_c�7 <br /> Category __ Descri tion _ Units Qunnti Rate _ _Total <br /> Administration Adminislration/managemenl Hours __ <br /> Labor CGTVlnspeclion Hours _�__`_�,�� �� __ <br /> ` BNN lnstall Hours _ _ _ <br /> Pipe replacement Hours =___ <br /> Suriace restoration Hours _ � y � <br /> Sito cleanup Hours __ <br /> Downspouls/drainagn imp. _ Hours _ _ <br /> Materials Buckwaler valve Per Unil {' � ��� <br /> - - (._��k l�fl5_-- <br /> Grinder pump Per Unil __ <br /> Side sewer pipe(up ro 8 feet) _ Feet � �� _�G��,7 __��___f <br /> Imported Backfill __ Yards _ ___ _ ,___ _ <br /> -- ���� Surface Resloration Materials Lump � <br /> __..._�—.__ <br /> l0 SOI��9f85S SB0f1,COf1Cf81Q PIC�__ SUffl ____ _� f . <br /> Cover(irrigation bo�or load hearing Pr,r Unit <br /> cover)- -- --- - -- � --�o�-. —��"Z, — - <br /> -- `-- — Hour <br /> Rontals S ecify equipment _ _ _ __ <br /> _ _ �ri�� — - — l— �_ 3�� <br /> -- — — — - - - - — <br /> Fees � � Dispnsnl f�rs hy itr.m Yards a_�.! <br /> _ ___ <br /> _ _—. _ ' . . _ _. _. _—.. __' __. .__. .___ _ __ '_. <br /> . . . - Ur.lwerylcesifnotcoverrdbylahnr _. . . ._ _ '__ ._. _____ ._ { <br /> -- — -- — — — . ._- —� — -- - - . <br /> Eli fble Total $ ' . <br /> Other Costs Cosls nat assucialed with�WD, and <br /> not eli iblc far rebate�tail be�ow)_ __ ____ ___ _ .—� _.—._ <br /> — -- -- -fl�—�- � <br /> ___ _ � _ -- --- --- - — - - k75 <br /> ------ — ._. _ ,�„�"^- �(_-- - <br /> —_— - f¢U-�y-0,-��.�,�ii <br /> Ineligihle Tutal ----- -- --- -- ' �4T� ryp <br /> Total -- -- — --- ----- $ a�r�6- <br /> Revised 9/P3/2014 <br />