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' BACKViIATER PREVENTION PROGRAM '�, <br /> INVOICE COST BREAKDOWN ' <br /> Please use this Invoice Cost Oreakdown as a tempiate for invoicos submilted as part of the Backv�ater <br /> Prevention Oevice rebate program. Either this form or your own invoice form with the tollo���ing line items can <br /> be submitied. This allows you to invoice your client acco�ding to your existing billing templaie white allowing <br /> city stali to identd��ho�v cosls eligible for the Backwater Prevention Devi�e Rebate�vere accrued. <br /> Only labor and materials directly related to tfie installafion and(unction of a backwater prevention <br /> device are eligi6fe for C!ry rebate and therefore should be inciuded on the upper hai/of this form. <br /> Additional costs may be added to boifom of fhe/orm. <br /> � ����,5r�t�,,� /'c� <br /> E3usntess Name:.�y�%�.�G�z!'1� � ���-•7�r vr License Numbec _�r7��i�i`7"•\ <br /> Business Mailing Address: b��'�c Ll:c[�c1�1 .__�J�E-• r��'�"P� «� U��� �.C� 3 <br /> City Sfate Zip <br /> Phone:,�In�.�/C�•-�N��� Email: i �>nplCCir,�������LItL.�,d�SN���'�9 <br /> ��� Catc�o�_ Deseri tion Units Quanti Rate Total <br /> Adminislration Admimsiration/management Hours` _ <br /> La6or CCTV Inspeciion Homs _�� _ <br /> BUJV Install Hours <br /> Pipe repla�ement Hours -�{,� <br /> Surface resloralion Hours <br /> f Site cieanup Hours <br /> Downspouts/dreinage imp. Hours <br /> Materiais Bociovaler valve Per Unit ���_&F�;�y����_� <br /> i Grinder pump Per Unit J <br /> � Slde sewer pipe(up to 8 teel) Feet �� �' �__�.a <br /> Impotted Backfiil Yards <br /> I Surfate Restoration Materials Lump <br /> lo soil rass seed, concrele,etc._ sum � � �_ <br /> i Cover(irrigation box or load bearing Per Unit — <br /> cover) �- -� <br /> LRentals Spocify equipment Hour ' <br /> � �.,n�__�� - —� <br /> -- ; <br /> Fces Disposallees by i�em Yarde - <br /> _ -���7= 1 <br /> Dr.livery fec,if not r.ovcreA by labor _ <br /> �- -- ---- - --� -- - - . . — - --� --- ----- <br /> I--- ------------ -- �--- -- ------ --- . g � <br /> I Eli ible Tolai ' - . �) oZ <br /> I Othcr Costs Cosis no[associated with DWD,and <br /> nol eliqible tor rebate(delail below� _ ____ _ _ _ ____ ___ <br /> I— ------ --- -- — ��=� -� � ccltt�--�� — - <br /> ,��� �� -- <br /> --- --- ---- — tr� . ( . .,rv � �v <br /> � <br /> Incligi6le Total �" 5 <br /> � Total — � � - � <br /> Revised 9/03/2014 <br />