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BACKWATER PREVEIVTION PROGRAM <br />E INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a temptate for invoices submitted as part of the Backv+ater <br />Prevention Device reba;e program. Either this form or your o�vn invoice form with the follovaing line items can <br />be submitted. This allov+s you to invoice your client according to your existing billing template vohile allowing <br />cily s1aN to identify ho�^e costs eligible for the BacA���ater Prevenlion Device Rebale tivere accrued. <br />Only labor and materials directly related to the insfalfation and function of a backwaterprevention <br />device are eligible tor Ciry rPbafa and iherelore should be included on the upper half of this torrn. <br />Additional cos(s may bo added to boftom o( the (orm. <br />��'cc.t'C, Lu: <br />Business Name: �lYzJa�.�7�-�SIC�=' License Numher _QS�ai �:�_.— <br />Business Mailing Address: <br />Phone: �.%•-�/C� -';.Y?��: Email:� �� r � ,� G lUQ �;[i�'�N,.�Y°(: Ck>,73� <br />Reviseil9/03/2014 <br />