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BACKWATER PREVEIVTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> P!ease use this Invoice Cost Breakdov+n as a lemplate for invoices submitled as part of the Backwater <br /> Prevention Device iebale program. Either ihis fonn or your own invoice form e✓ith Ihe foilowmg line dems Can <br /> be submilted. This allows you lo invoice your client according to your existing billiny templat�white allowmg <br /> r,�ty slaN to ident�fy how costs ehgible for ihe Dackv�aler Prevention Devir.� Rebate were accrued <br /> Only labor and materials directly related to the installafion and function of a backwatei prevention � <br /> device are efigible (or Ciry rebate and therefore should be inchided on the upper half of this (orm. <br /> Add�Gonal coslS ma}�be added to bottom o((hc form. �J �4 <br /> sE��'(' �" /, I <br /> E3usiness Name: I�(�'�(°/�}.,<<��idF- License Numbe�: ._�S`.��'7_.� _--_ <br /> � -►"___ <br /> Business t��ail�ng Address: t�(ct-�: ��`����_____r-1�La-�'� �'�� �`��-'� ' <br /> City State ��p � <br /> Phon�, �'f.=•�(�:-�,.,"S�, _ [mail:�f.iiv�C(sta��i..G1.�-�(l�.�deSrl��_� I <br /> Catc or i Descri tion Units Quantity RBtc Total i <br /> !-- -9-Y - - --f' ' <br /> 4 Adminislretion Adm���u;traUon 1 management Hours _ _ � <br /> �Labor __ � CGN Inspection __ Nours �_� -a <br /> ..•.pV�.^J instail HourS _ _ <br /> Pipe replar,errent Hours— � _1_c,. ,`�--� <br /> �-- f- --__--- <br /> Surfacc restoialion Hours � ��" <br /> i - —�------- Hours -� <br /> � Sile cleanup — <br /> � Doa•msoou�s/drainar�e imp. Hours <br /> � Maleria�s Backw�ter valve Per Unit �f���_., �.L'��� _-�_--��, <br /> Grinder pump Per Unit <br /> � Slde sc�tier pipe(up to 8 feeQ Feet g"J- �' �Q� �� r57 <br /> Imporlcd Back1111 Yards _ _ <br /> Surface Restoralion Wleterials Lump <br /> I �top so��_grass seed, concrete,etc.L sum_ I c� __,�c� <br /> i Cover(irrigation box or load bearing Per Unil <br /> --�-- ��� _l.� <br /> Covcr _.---_ - <br /> � RenWls Specify equipmenl Hour _ ___ <br /> ---. - -�'�'��-►�-� ___.3�0 <br /> i Pces �--- -� -Disposal fees tiy item Yards I <br /> - -- - � -- - _���_'� � <br /> � - - -- -- �--� --- ----- <br /> - � � Ur livcry fr.r if noI r,ove.icd b IaUOr � <br /> --- ._----- �-- � - -- - ----- <br /> I [Iiqil�le Tolal - l . � .. .- ---�-- - ---�� -- � ,�'" 5 , <br /> Other Costs CuSls nul associated wdh B'ND, and <br /> not eligibie tor rebate(dr.tad bcloe�) _ ______ __ __ <br /> --_ -__- - _� (�- _�-�----�ti� _��� ���-� ---- '', � <br /> — _ -- —_--������ ��3 — ---- , <br /> Incligiblc Total �v'^ � �' <br /> Total - ---L------ -- -� -lC(`H.. �d� � -n — - <br /> � � Z — Ic� - 14 <br /> Revised 9/03/2014 <br /> � <br />