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BACKWATER PREVEfVTION PROGRAM <br />INVOICE COST BREAKDI�WN <br />Please use this Invoice Cost i3reakdown as a template for im�oices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your .,vn invoice form with the iollowing line items can <br />be submitted. This allows you to invoice your client according to your existing billing template while allowing <br />city staff to identify ho�v costs eligible for the Backwater Prevenlion Device Rebate were accrued. <br />Only labor and materials directly related to the installafion and function of a 6ackwater prevenfion <br />device are eligible for Ciry rebate and fherefare should be included on the upperhal/of this (orm. <br />Aodifional cosfs may be added to bottom of the Iomr. <br />5�cu°%, l,�-�:- �y <br />Business Name:�l"�-,���_�j;Gc�!-; � c? License Number: �J�� :1 <br />Business Maiiing Address: oS(�z�lc L.Gc /"��!'t t��k-• 1= VNfCXl -�h i��� •�S <br />City State Zip <br />Phone:��'.�}� ��,Y]�=� Email:('i )i�r�� S�llii�r.3i�p,-��°f= C'cS3Y1 <br />,lN <br />Revised 9/03/2014 p.�z��� <br />