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BACKWATER PREVENTION PROGRAM <br /> �T INVOICE COST BREAKDOWN <br /> Please use lhis Invoice Cost Breakdovm as a template for invoices sul�mitted as part of the Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form with Ihe foilowing line ilems can <br /> be submitted.This allows you lo invoice your clienl according to your exist�rg billing template while allowing <br /> city slaH to ideNify how costs eligible for the Backwafer Prevention Deviee Rebate were accrued. <br /> Only labor and materials directly related to fhc lnstallaUon and function of a backwater prevention <br /> devlce a�e eligible for CIry rebate and therefore should be inclu�ed on the upper half of this form. <br /> Additronal costs may be added to boftom o(the(orm. <br /> 51"t:tl'�- �.G /,"� <br /> Business Name:,�/��rz��j,c. ��r_5.(L'�e License Number: _(;J�J�if�`lt) <br /> Business Mailing Address: v�fix�c� LEt!',�Vl ���-• I��l��f ���� p����3 <br /> City State 7_ip <br /> Phone:�•.�jp-'��� Emaii;G� ' ' rrcrn��_L}lj�����ecrF� C'�SYYI <br /> Catey� Ooscriptlon _ Units Quanti Rate Total __ <br /> Adminislralion Adminislration I managemenl Hours <br /> Labor CCN Inspeclion _ Hours _L_ �j(� ___�� <br /> B1NV Install Hours <br /> Pipe replacement Hours <br /> Surfece resloralion Hours ((� <br /> Sile cleanup Hours <br /> t7owm,pouts/drainape imp. Hours � <br /> Materials Oackw�lervalveJ PerUnit `�� �t L� <br /> Grindor pump Per Unit <br /> Side sewar pipe(up to 6 (eel) Feet �( - � <br /> Imporled f3ackfill Yards _ <br /> Sudace Rc,loration Malerials Lump <br /> �lop soil grass seed,concrete, etc. sum ___ ��U vd <br /> Cover(ini�ation box or load boaring Pnr Unit <br /> cover)---- — / �- /� y <br /> Rentais Sper,ify�e�q�w-�—rtiont Hour _ I <br /> -- -�-,�1�u-�t�za"— _—�. �� <br /> Feos �isposal fece hy ilem Yr��G q��_�. � I <br /> O � ' � <br /> Dclivr.ry tecs i(nol r.overed by lahor _ __ ___ ___ � <br /> Eli iblc Total - -- -----�— — - --- ------ 'Q!': . � — $ -, <br /> Othcr Costs Gosis nol associa�ed with DWD, and <br /> __ not elic ible for rebato detail below) __ __ _ _ ,_ __ _ <br /> — - �Iv �o�can acfW- _ <br /> --- — -- V1.Tq7I_ -- – -- <br /> -- - -L-�"`-- y""- - -- <br /> -- -- '�,.�.. <br /> lneligibla Total �G ���f <br /> Total _ . — — ------ -- ----------- �'����1��'c(�- <br /> Revised 9/03/2014 <br />