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. 1 BACKWATER PREVENTION 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. Either 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 staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials directly related to the installation and function of a backwater prevention <br /> device are eligible for City rebate and therefore should be included on the upper half of this form. <br /> Additional costs may be added to bottom of the form. <br /> Business Name: MIT-pt ifmbi1 j U C License Number: ,419- -Y / 6/// I\ <br /> Business Mailing Address: j,$i'f /gist-ii'' .. wp4- 9 8 <br /> City State/ Zip <br /> Phone: S 4(97-orz 3 Email: 19t4-t�A-kind Lj //C g4/7(" �rj'��`hL.� 491A. <br /> Category Description Units Quantity Rate Total <br /> Administration Administration/management Hours <br /> Labor CCTV Inspection Hours % ©cf:' <br /> BWV Install Hours / /5 j 0 <br /> Pipe replacement Hours S—c) <br /> Surface restoration Hours t/ 4 S-0 <br /> Site cleanup Hours T 8 p <br /> Downspouts/drainage imp. Hours <br /> Materials Backwater valve Per Unit ( <br /> Grinder pump Per Unit <br /> Side sewer pipe(up to 8 feet) Feet <br /> Imported Backfill Yards ! `7 <br /> Surface Restoration Materials Lump <br /> (top soil,grass seed,concrete,etc.) sum <br /> Cover(irrigation box or load bearing Per Unit <br /> cover) <br /> Rentals Specify equipmentHour <br /> ✓ <br /> Fees Disposal fees by item Yards <br /> Delivery fees if not covered by labor <br /> Eligible Total $ <br /> Other Costs Costs not associated with BWD,and / <br /> not eligible for rebate(detail below) <br /> gr..7 62 <br /> Ineligible Total $ <br /> Total $ <br /> Revised 9/03/2014 <br />