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u�R�4��JUA�E�: P!:lEVEN�lON �'�O�P.AlV! <br /> Q' INVOICE COST BREAKDOWN <br /> Please use lliis Invoice COsI BfeakdoWn aS 2 tentplate for invoices submitted as part of ihe Backwater <br /> Prevenlion Device rebate program. Either this form or your ovan invoice form�vith the follo�ving line items can <br /> be submitted. This allo�vs you lo invoice your client according to your existing billing template while allo�ving <br /> city staff to identify how costs eligible for the Back�vater Prevention Device Rebate�vere accrued. <br /> Only laba•and materials direc[ly relaied to iiie instellsf�on and�unction of a back�+ater prevention <br /> device are eligible/or City rebate and therefore shou/d be included on the upper half of this form. <br /> Additiona!costs niay be added to bottom o(the form. r �g <br /> ���v�L_ � Se"� License Nuinber:� 'v�^�' v�,�-��� <br /> Business Name. S �s � ut�d <br /> Business fJailing Address: �� �3�a� S-�. .S� �dh��t{7'S W� ��6 <br /> ^�/� n' IJ�, y Cilyr' State Zip <br /> Phone: dv'�.U � • L �'�� _ Email'�f/�n��les�2r,t�SCu,�R Cni �A.[4i�.Go.� <br /> � Category Descri tion Units _ Quantity Ratc ToWI <br /> Administration I Adm'ni,iralion/managemenl Hours _�_ <br /> (L—-- Hours <br /> Labor I CCTV Inspection �___ <br /> p\NV Install _ Hours <br /> Pipe replacement Hours . <br /> Surface restoralion Hours � O <br /> � — Hours � <br /> I Sile ctcanup <br /> f Dowr. �outsldrainageimp. Hours � <br /> � Materials Back�vater vah�e Per Unit �'��p0 <br /> ` Grinder pump Per Unit _ _ � <br /> � Side sewer pipe(up to 8 feet) Feet <br /> G-- I <br /> i Imporled E3ackfill _ Yards <br /> Surface ftestorafion Materials Lump <br /> _to sod, rass seed,concrele, etc. sum <br /> Cover(irngalion box or load heanng Per Und � 2S 00 <br /> cover) <br /> Rentals Speafy equipment Hour <br /> Fees Dispasal fees by item Yards y af7•�_ _ <br /> -- ' �"oT,�i C <br /> - -- a��-oo - <br /> Delivery fees if n��l covered by labor ___ __ .5[;._ ______ ___ __ __ _ / CeS�' <br /> - - - - -- - - -- K �L°,3,ao v, <br /> Eliqible Total ' �'� � <br /> Other Cosls Costs nol associated e�dh L3WD, and — -- <br /> ❑ot eligible for rebale(detail belo�v __I __ ___..___ _ <br /> ' ------ - 01 ��JfX -�6V1)�'11C��!�Y-IVUL�� � <br /> --— ____��. 3�i33� -- <br /> -- �-- --- -- -- ---- — �G � - �nnbG+�l <br /> _� — � <br /> Ineligible Total � I � ��Z�f �� <br /> To[al _ _ _ I— -- -- — -- -- — ---,--L-- _-1------�-- <br /> Ret�ised 9iO3%101a i <br />