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BACKWATER PREVEIVTION PROGRAM <br /> � INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater <br /> Prevention Device rebate program [ither lhis form or your own invoica form tvilh the following line items can <br /> be submi�ted. This 311ows you to invoice your client according lo your ezisting bi.ling templat�while allowmg <br /> city slaff lo idont+fy how costs el�g�ble for Ihe Back�vater Preventio� Device Rebate were acr.rued. <br /> Only la6or and materials direcUy related to the installafion and funr,fion of o 6ackwater prewanfion <br /> devlce are eligl6le for City iebate and therefore should be included on fhe upper half of thls (orm. <br /> Additional costs may bo added ro 6ottom of�he lo�n. <br /> Sp`u;!_, I.C.c.; /' <br /> Business Name:�l�'��l,rz('] ��.�-�rS�L'L-License Number. _ __Q5�-1�_ __ ___- <br /> Business Mading Address: aG%C-�_ L,l���iL►ly�-• __(�f f�1L--�r�n—���.�— <br /> '���- City Slate Zip <br /> Phone:�.�,_,�1:�_"�`�,� . --- Email.�ic.Kt�LUI��'�s��7�_c.w�t_�;deb�L�G�7y! <br /> -- -- — <br /> Category•_ Descnption__ ___ _Unils Quanti RAte _ _ Total <br /> Adminislratio�Administralion/management Hours �� __ <br /> - ---- t <br /> ---- -- --- - - -- <br /> Labo� 1CCTVInspeclion Hours _ 9 � ;�5,��.___ <br /> --- - - --{--- <br /> � A1NV Install Hours <br /> Pipe replacement Hours _ <br /> SuAace restoration __ Hours _ __, <br /> Site cleanup Hours ___.__ '� <br /> Dnwnspouts I drainage imp Hours __ <br /> Materials oar.kwaler v;iive Per Unil 1r __��11�7� __��-- <br /> ---. . <br /> - -- <br /> Grinder pump Per nit <br /> -- -- - <br /> ---- -- -- ---- <br /> Side sewer pipe(up to 9 feet) Fee� ���n a'q � - �-_- <br /> - -- <br /> - --- <br /> Imported Backfill Yards <br /> -- - - ------ - -- <br /> -- ---- --- - <br /> -� Surtace Restoration Matcria�s �-ump <br /> ---- . <br /> Lop soil, grass seed, Concrete,etc) sum ___ (��__ -�.�-__ <br /> Cover(irrigalion box or load �earing Per Unit <br /> � cover) _ `�`.-- <br /> --- --- - -- ---�.--- -�_- <br /> � '`' -- Hour <br /> Rontals Specdy eyuipmenl _ _ _ ___ <br /> - - — <br /> �'1!�t�- _ k�i�— __ _ - /--- —� � . " <br /> -- - <br /> - --- - - - - — -��-� <br /> — - <br /> Fces Dispo o� frr s by il�m YarAs <br /> � _— <br /> __ .. - . _- . _ _ ,_ ._.__ ___ --_ .. _ . <br /> -.-_ ._ -. . . _ - — _ .—_ <br /> � Delivery lecs il nol covnred by lobor .. .. <br /> - � -- - � �------ - - - - �- - -- - -- � <br /> — - �- - .. -�-- ��- �-- <br /> Eli ible Tolal <br /> Other Cosls ��sls not associaled wilh BWD,and <br /> nol eli ible(or rebate(delail belo�v)_ ._ __ _ _. . .. .. _— <br /> --- ---._ -- <br /> __ _ . 1� PA_1.�i��S�ct.�1 Lnp . __- - — - (��P�-— -- lA�Z- <br /> --- -- — -- _- <br /> - -- - --- _- - ----- <br /> U�< <b Creo�"u'�ti✓ -- <br /> _ __ -____—__._ .—" <br /> . . _. __. __. _ _ _ <br /> . , <br /> 1-ucc�(� ^- . 335L _ - <br /> Ineligi6le Totai - ---- ---- - ^a`^4 � �f� $ '- <br /> Total __ . -- -- --- --- - - - - --N',�1 �c.�24Yd� _ _ $r�. �__� <br /> - a/ G/��. <br /> Revised 9/03/2014 <br />