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BACKWATER PREVENTION PRiDGRAM <br />INVO'CE COST BREAKDOWN <br />Please use this invoice Cost Breakdown as a lemplate for invoices submitted as part oi ihe Backwater <br />Prevention Device rebate program. [ither this form or your own invoice form with the following line items can <br />be submitted. This allows you to invoice your client according to your existing billing template while allowing <br />city staN to identify how costs eligible �or the Backwater Prevention Device Rebate �vere a�crued. <br />Only labor ard maferials directly related to the insta/lation and function of a backwater prevenfion <br />device are eligible far C!ty rebate and therefore should 6e included on the �pper half of ihis form. <br />Additional costs may be added to bottom o/ the (omr. <br />5�,�u,� ;. ��c� �. <br />8usiness Name:NJ'Y�Pri���v'�l�' �-g;-�iL� License Number. _���� _ _ <br />Business Mailing Address: oiG�-(c LG[!"4cV� 1� v= • ��(/�� � i �,{!l I <br />C�tv State <br />Phone:��:,(,�- 'O � � � -� Email :CJ ' � t1C�C��� L L,�.;rl� C;-, , 2�!'. C' ��"! <br />Revised 9/03/20i4 <br />