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i <br /> �Aa��'CVVfAI'�R G��Y�if'�NTCO� �faOQ3��111i6 i <br /> 1�9V�IC� �0�� �i��141(�O�VVN , <br /> , <br /> Please use this Invoice Cost Breakdown as a templato for invoices submitted as part of Ihe Backvuater <br /> Prevention Device rebate program. ENher this fortn or your own invoice iorm with the following line items can <br /> bea submitted. This allows you to invoice your client a�:cording to your exisling biliing tertip;ate while allowing � <br /> city slatt to identify how costs oligible for the Backwaler Prevenlio�: Dovfce Rebele were accrued. <br /> Only laborand maferials directly relafed fo the lnsfallaPion an��function o(s beckweter preNention <br /> device are elrg7ble /or City rebafe artd therrefbre should 6e inci r�ded an the upper hal/o/fhls form. <br /> Addrtional co�fs may be added to boltom o/the (onn. I <br /> i <br /> Ousiness Name 'n � � �'t!_L.L .C. License Pdurnber. �u l � )L�'!�� : <br /> �J ' <br /> Business Mailing Address: _ .�� �/�1_�:27`-it✓ctir'L.t ��� -��,P?2�=� G��✓�"_�,12 G�. � <br /> City Stele Zip � <br /> Phone: �� ` ��`�-U(Z L. Email: /�1�'f���l��lOj�'�.�_LLL.�y�(��7i'�nL- -c'�--l'� <br /> Categ�__ Descri tion _ Units QuanNt RaM ToWI__ _ ,' <br /> Administrallon Administralion/menagemenl Hours _ ._ � <br /> i <br /> Labor CCiVlnspeclion ______ Hour; j �G'�� _ ____ <br /> - -- --— BVW Inslall Hour; i / Z 'i'z' <br /> � Pipe replacement _ Hours _ � <br /> Surface resloralian ___- � <br /> - ----- Hours _�z-' � <br /> Sito cteanup T_ Hours _ / `j� __ � <br /> Downcpouls/drainage imp. Hours _ ___ <br /> Materials Backwater valve Per Unit � __ J-7_' ___ ; <br /> Gnnder purt p Per Unit __ ___ ! <br /> -- Side sewei pipe(up to 8(eet) Feet _ . <br /> ImpoAed BncM�V _ Yards ___ ____ _.___ <br /> Sudace Restoration Materials Lump � <br /> to soil rass smd,r,onr.rcle,etc. sum � �� � ' � <br /> -- -- �-F-'9.— . . ---- . - --- _ � <br /> Cover(irtigafion box or Ioad 6eann{� Per Unit ; <br /> eover__ -- _ . . — - --- ' <br /> — - ---- ' <br /> Rrsntals Specity r.quipment ___ Hour _ _ __ _ _ _ <br /> ----- - ---- — — � <br /> — --- -- --' — <br /> Fees --- -- Diseosal(ees by Rem_-- — Yards - - - - -- --- � <br /> --:Y7�tA r_� . . __ - - ---�-- ----- --'-- ''��. - i <br /> "' _ __ __- . � <br /> : Dclroer/ler.s d not covered by labor _ __ _ _ —__ —_. , <br /> -- -.^ - -- <br /> . ^ <br /> - - - __ -- -- - --- $ ��'3=�; = - ; <br /> --- ---- � <br /> Eliiblo Total .._.,.,,,�..�..�._,._..,.,,,,..,_„_,._ a.,r.�.x, ' <br /> OthM Costs Cosls no�associaled with BWD,�nd _�� _� L �t ?�-� � <br /> not eli�le tor re6ate detail below�__ __.._ __ � �_ ____.- � <br /> -- -- _ _ _ . <br /> — . ---- —— -- ' _` <br /> V <br /> _-- -- _- -- -- <br /> -- -� � <br /> �� l ' <br /> — - - L� __ <br /> . <br /> -- - - --- - — -- ' <br /> Ineligibie Total ----� . _ $ <br /> Total g � <br /> Revised 9/0312014 <br />