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i <br /> I <br /> ; <br /> ���Kt+�����t ��E!!'I�B����3� P�t4C��4f�fl I <br /> �N@�OG�� C�S�' �FiEAKD()VN� � <br /> Plaase use this invoice Cost Breakdown as a template for invoices submitted as part of the Backwater ( <br /> Prevention DeviCo robate program. Either this form or your o run invoice torm with Ihe following li�e items can � <br /> be submitled.7his allows you to invoice your clienl accordin�to your exisfircg billing template while allowing � <br /> city slaff fo identify how costs eligible for ihe Baekwaler Prevention Device Rebete were accrved. � <br /> i <br /> On1y iabor snd ntafetiaPs divecdy reiaPed to Phe Fnstaffation attd Function of a backwafer pnevention � <br /> devicc are e1I�iDPe for CiQv eiebate art�f therefore sEroulrf be includeaF orr the srp�r half of this dorm. � <br /> Addifiona!costs may be added fo bottom of fhe form. ; <br /> Business Name: /�f� ��G�� :'to61� i / G License Number. I/�-f}-I-��✓/ �/)//I�L� I. <br /> Business Mailing Address:� l4 / l//�57`ZLiWtU'vL� �l.�= -t-,'�Yt�=�-� L.h11- g�� `G� ( <br /> City Slale 2ip I <br /> Phone: �5 'f-�rU`�-OlZ3 EmaiL• " ���r�/� ri �[[ : �-/�i `' �'?��i�9eL:(_ �'�'Ll ! <br /> CaMgo Descri Hon Uniis Quanti Ratc Total � <br /> ddministration Administration/managemenl Hours � <br /> Labor CCNlnspectlon Hours � `�iGC'J � <br /> -- DWV Install Hours � 7 `>G � <br /> — Pipe replacement Hours � <br /> Suriace resbralion Hours �/_•'�-=' <br /> Site cleanup Hours �T: <br /> Downspouts I drainage fmp. Hours i <br /> �aterials Backwatervalue PerUnil 2_•j�-' 1 <br /> Grinder pump Per Unit � <br /> Side sewer pipe(up to 0 feet Feet <br /> Imported BacMill Yards � <br /> Suriace Restoralion Maferials Lump , � 1 C� � <br /> ro soil, rass seed,concrele,elc. sum � '7 J j <br /> Cover(irtigatlon boz or load bearing Per Unil � <br /> cover) � <br /> Rontals Specify equlpment Hour f <br /> 1I <br /> 1 <br /> Fees Disposaltees byileci Yards � <br /> ��irsl.t�'� ! '�� � <br /> „' Dclivcry fees it no[covered by labor � <br /> �!i i6ic 7otal —� $ , _ `� ~ � <br /> Cosls not associaled wilh BWD,and � �_:___ I <br /> Other Casts nol eliqible for rebale(delail6eiotiv '� � ' ��'�' �' � <br /> ! <br /> �s �U � , <br /> _ , <br /> , <br /> I�eilgibfeTofal • $ ' <br /> Total $ � <br /> . � <br /> . � <br /> Revised 9/03120f4 • � <br /> I � <br /> i <br />