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f <br /> BACKWATER PREVENTION PROGRAM ' � <br /> I <br /> � INVOICE COST BREAKDOWN <br /> Please use this Invo;ce Cost F3reakdown a; a tem; !e for invoices submitted as part of the Rackwater i <br /> Preventmn Device rebate proaram Lithr.r'�is form youi own invoice form with ihe following line iterns can � <br /> be suhmi�,ed. This allows you to invoice your client a�cording to yuur existing billing template while allowing + <br /> city statt to �dentify how costs efgible for the E3ack�•�atrr Prevr.ntinn DevicP Rebatr avr,ra acr.rued I <br /> Only labor and materials directly related tu the installation and function o(a backwater prevenfion I <br /> device arr ellglble for City �ebafe and tl�ere(ore sliould be included on the upper hall of this torm. <br /> Additionnl cnsfs may be ndded to hottom o/thr. /orm. I <br /> �rccl'{;�('< V <br /> Business Nama�1l�-j�c.e1� 5c'-�+c..c�, ;�����P,� License Number. --(>��,j'�j��:_\_ _ � <br /> -- i <br /> Rusiness Mai6ng Address. r�G:G-�._L(tI_4�l'l-. i�J�E-:�--- -.--1--(,����'-�1 _ _��_.._C!S':�Q�'a- -- i <br /> City Stalc Zip <br /> f'hone ��,.���C��;k:`.� ___ Email:�.�Q!!k'l�<ci�1����Uilri�S,dt'Sr�.c:�_(�SvrI9 I <br /> - _-- - _ - -- -- - - — _ <br /> Calegory � Desenption Units Quanli Rato Total _ j <br /> - --- - _- <br /> Administralion � Adrrinistration! manayement htours <br /> --- ' --� - - ---- - --- - -. _ . ._ -- - _ . <br /> � Labor CCTV Inspe�tion Hours ��j t��Z1 � <br /> -- - — - <br /> --- <br /> RI^IV In,tall Hows ._.-___-- _ -_— _-. <br /> -- - - -- �- --- --- - - -- - - ._ _ <br /> � Pipereplar,emPnl _ Hours_ — --_- - _� <br /> 1 � -- -- . ..- = <br /> f Suriace resto�atior Hours �_ i�(,� ��� <br /> _ -._. � - - — - - - <br /> Sde ciranup Hours <br /> �- - — -___ . _ . - HOurs _.. — --- -— <br /> DownsP��uts I dramage Imp __ ._ <br /> -- - ---- � - �---. . . . — --.. _ <br /> Materials H u.kw�ler vnlve Fei Und {�f�,�U ,� ��j(�..._ -- �� .. . <br /> Gnndmpump �ci Una __' � <br /> -- -- - __ T--- � . _ - <br /> Side se�+�r pipe(up to 8 fert) Feet � �-f� � �G��� <br /> . ..----_ � - . _-- . _.. . _ _. .._. - ( <br /> � Imported Aackfi l Yards <br /> - - <br /> -- - -- --- _ --- � <br /> Surfece, RF.^.!or�Uon Matemi Lump <br /> I jlop soif grass seed,con ete,et� sum _I _ _ "�'�Q_ _ �(� _ <br /> � Cover (i�rigat on Gax or load bcaring Per Und <br /> �o��__ -l- _. l � _l_�- <br /> Rentals Specify cywpiner�l f lour � <br /> _ ._ . <br /> _ _ --- <br /> -- ��1.�Q.��L= �e. _ _� �Jk�L - -�� ' � <br /> -� — - ^��7 <br /> - -- -- , - __ _ _ - _ <br /> Fers Cli�posal}ers by ilem i Yards __. .. _ _ .c�a 2./ � <br /> - . . . - .-.-- . -�_ .- - <br /> --- - ---- - ----._ . - -� - --. .._.-- _ . .. I <br /> -. - -- Uelwery fees il nr�i cuviscA bY__labor . - --_ _' ,—'— '- . .- I <br /> EG ible lotal _- .. . . . .--- - - -- - - � -- � � � I <br /> Olher Costs Custs nol associatetl with BW�, and � <br /> not e��hle lor rebate delail belo�v) I <br /> __ _. _. . ._. . _ <br /> "__ " _ <br /> ...- - M` f_. <br /> - ----- --- - -- __ Q�[ k' �'7 - . n:r tl� <br /> _ _ — �ro <br /> u �.-_ v(3�11} � <br /> --- --- �-- � --- r -- - <br /> �- - - - - - ----- - - - � ----- �- - ___. <br /> — � ` `�I � <br /> � - - -� � - - -_ _- . . ���.,�_ (�.,-.�..�� � <br /> __-. . . _ - --��-- ----- - -- -.. - --- - <br /> Ineligiblc Total � Q ��7� �r , <br /> �� Tota� I --�— _ $c� 3 __ � <br /> -- -- -- __ f <br /> I <br /> RrviseJ 9.iO3/2014 <br />