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i <br /> BACKWATEF� PREVENTION PROGRAM ; <br /> INVOICE COST BREAKDOWN � <br /> Please use this Invoice Cost Breakdown as a femplate for invoice� submilted as part of Ihe Backwater I I <br /> Prevention Device rebale program. Either lhis form or your own invoice torm wilh the following line items can I i <br /> be submitled. This allows you lo invoice your clienl according ro your existing billing template while allowing i <br /> city slaft t�identify hotiv costs eligible for Ihe Backwater Prevenlion Device Rebate were accrued. ; <br /> Oniy labor and maferlals direcfly relafed to fhe installation and funcfion o/a backwater prevention ; <br /> device are efigible lor City re6afe and fherefore should be fncluded on the uppe�hall ol fhis lorm. <br /> Additional costs may be added tu bottom o!the torm. ; <br /> Dusiness Name _/�J�P��it�(J Y� 1-/_C_ License Number. _�fi_�juL���� � <br /> Business Mailing Address: ���IJI S��-�'✓��_r I�V FV��`�'� 9� b�' j <br /> Cily Slate Zip � <br /> Phone: �IZ-� - LI 8 S" � /2 � Email:__}4_L4���� C.LL a�/-)�����a�� <br /> , <br /> Cate9orY___ Description Units Quanlity_ Rate _ Tolal i <br /> qdmfnistralion � Adminislration/managernenl Hours � _ � <br /> � <br /> Lahor CCN Inspeclion Hours 60 _ � <br /> _ i <br /> BWV Ins�all Hours j ��O ; <br /> Pipe repiacemenl Hours / _'z'S�_ _ j <br /> Surlace restoralion Hours + <br /> SPecteanup Hours / /S_� <br /> Downspouls 1 drainage imp. Hours _ _ � <br /> Materials Backwaler valve Per Unit / _ 2SD ' <br /> Per Unit � <br /> Grinder pump _ — - • <br /> Side sewer pipe(up l0 81ee1) Feet <br /> Imported Backf ll Yards � <br /> G, � Suriacr. Reslorat�on �dalerials Lump � � � • <br /> —�'�,lL , �o soil, rass seod concrete,etc. sum � <br /> --�--L�_�_--'-- - <br /> Cover(irrigation box or load bearing Per Unit ! <br /> � <br /> cover) � . _.— ' <br /> Rentais Specity e uq ipment Hour _ _ � <br /> � � 3�' i <br /> - -��.wu..i -- <br /> Fees Disposal fees by ilem _ Yards ` <br /> Delivery fees if not covered by labor _ __—_ _ __ ' <br /> — -- - -- -- - - i <br /> Eli ible To[al -- ---- -- — - --- $ �i��'�� � . <br /> I Other Cosis Cosls nol associaled with 81ND,and ..� i <br /> nol o�igible for rcbale Lail helow � ; <br /> -- --�-� 2-� � <br /> - ---- , <br /> -- - - _ -- - ?�l ; <br /> Ineligible Total $ ���� , <br /> Total -- — -. . � . <br /> Revised 9/03/?_014 <br /> i <br /> V <br /> i <br />