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BACKWATER PREVENTION PROI�RAM <br /> � � INVOICE COST BREAKDOWiV <br /> Please use this Invoice Cost Breakdown as a template for invoices submilted as part of the Backwater <br /> Prevention Device rebale program. Either this form or your own i�voice form with the following line items can <br /> be submilted. This aliows you to invoice your client according to your existing billing template while allowing <br /> city staH to identity how costs eligible for the Backv�ater Prevention Device Rebate vdere accrued. <br /> Only labor and materials directly related to the installation and funetion of a backwater prevenfion <br /> device are eligibfe for Ciry re6aee and iherelore should be inciuded on the upper half of this form. <br /> Additional wsfs may be added to bottom of the form. �J <br /> 5����, �S�-�h�f�' <br /> Business Name:�qllzL2.0 , -c,q,., ' � License Number: <br /> �l�'-. ��1,�.��` t t lA ���c�.3 <br /> Business IJlailing Address: o��G� Lu[�L� � �i� Slate Zip <br /> ' Email_� � �)ri�1.�ri�c<n�,P,{i��.�L1[�S,c�-_�',�Hc��'(: C`c%YI'I <br /> Phone: `.2�v'�!D �%��� � <br /> Catc�ory Descri lion Units Quaati Rato Total <br /> Adminislratfon i,dministralion/managemenl Hours <br /> Labor CCN Ins e�lion Hours <br /> gWV Install Hours <br /> Pipe tepiacernent Hours � � <br /> Surface restoralion Hours <br /> Site cir.anup Hours <br /> Do�vnspouts/drainac�e imp. Hours <br /> Matariais Backwater valve <br /> � Pcr Unit 'i �g � <br /> Grinder pump Per Unit <br /> Side sewer pips(up to 8 feeq Feet �< <� GI _ <br /> Imported Backfill Yards — <br /> Surface Restoralion Materinls Lump 3 <br /> L soil, rass seed, concrete etc. sum <br /> Cover(irric��tion box or load bearing Per Unil � 1 � �� <br /> cover) — <br /> Rentals Speci(y equipment Hour <br /> —l——�a�-c? 3 b7 <br /> Pees Disposnl tee:;by item Ya�ds � <br /> . Delivery fees if not covered by labor _ � <br /> Eli ible Total —�----� � � $ <br /> Othcr Costs Gosts not associated tivilh BWD,aud — <br /> not eligible for rebate�lad belnvr) _ <br /> � (� � - h: c.. .l 4fS <br /> �I�+.� � <br /> _� t t.�a kt�.t.ai/ <br /> � _I <br /> $ <br /> Ineligiblo Total $ , <br /> �. <br /> Total <br /> Revised 9/Q3/2014 <br />