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BACKWATER PREVENTION P�tOGRAM <br /> INVOICE COST BREAKD�IWN <br /> Please use this Invoice Cost Breakdown as e template for invoi�s submitted as part of ihe Backwater <br /> Prevention Device rebate program. Either this fortn or your own invcice form with the following line items can <br /> be submitted.Thls allows you to invoice your client according lo your ex�:ti�g billing template while allowing <br /> city staff to identify how costs eiigible for the Backwater Prevention Device Rebate were acctued. <br /> Only labor and materials directly refated to fhe Instal/atlon and/unefion of a backwater prevenUon I <br /> deviee are epplbla for Clty rebate and thenefore should be lrtcluded on the upper haJf of fhls form. <br /> Additional costs may 6e added to bottom o/the/orm. U� <br /> tJC�- �r� <br /> Business Name: ari�� v� ���-S��e License Number. (7rJ��7� <br /> Business Mailing Address: o�G•�� t.E�L�c4l d�-• ���'� uJA 9��r�3 <br /> City State Zip <br /> Phone:�'�G,� > •'%]15Z:� Email:(�i� ��la,.,ivwrins.�n.Sc�� 4ide��r�l=CcSri► <br /> Ce o Doserl 8on Unita DuanB Ram ToUI <br /> Administrat(on Administratlon I management Hours <br /> Labor CCN Ins ection Hours <br /> BWV Instell Hours _, <br /> Pipe replacement Hours <br /> Surfece restoration Hour; <br /> Site deanup Hc�rs <br /> Downspouts!drainage imp. Hours <br /> Materials Backweter valve Per Unit 1' <br /> Grinder pump Per Unit <br /> Side sewer i u to 8 feet Feet �� « <br /> Imported Bac�ll Yards <br /> GJ Surface Restoretion Materials Lump <br /> to soll rass seed con�rete,etc. sum � <br /> Covar(irrigetion box or load bearing Per Unit ' <br /> cover <br /> Rentals Specify equipment Hour <br /> Fees Dis osal fees by item Yards <br /> �� <br /> Delivery fees if not wvered b labor <br /> EII Ible Total S <br /> other Costs Costs not assoGated with BWD,and <br /> nol eli ible for rebate detail betow <br /> v <br /> Inelf ible Total � $ <br /> Total $ <br /> {F(� �`l-� S-� <br /> Revised 9/03/2094 � <br />