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BACKVIiATER PREVENTIQN PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a template for invoioes cubmitted as part of the Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form with the following Iine items can <br /> be submitted. This allows you to invoice your ciient according to your existing billing tempiate while allowing <br /> .cfty staff to identi(y how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> Only la6o►and materials directly related to the installation and functton of a 6ackw?ter prtvenBon <br /> devfce are eliglble for Clry rebate and therefore should be included on fhe upper ha:'oithis form. <br /> Additional costs may 6e added to boRom of the form. <br /> Business Name: ��r.��i�'7�oRa�t uuc}�e�fc�e^se Number: A���I$5 V "/��55 <br /> Business Mailing Address:���3 ��fi� S � � �' £`�""""� �� �g�'� <br /> ,�_/ /' /� I ity p State �1 Zip <br /> Phone:dC� ' �jOS"7��� Email: H�So'u`1�S�olZ"iti„IXSI:��WG'Mcci�• Go/y <br /> �.eM o Descd tlon Units Quanti Rate Total <br /> Adm(nistratlon Adminfstration I manayement Hours <br /> Labor CCNins ection Hours .OG . Oa <br /> BVN/Install Hours O,m0 O. <br /> Pi e re lacement Hours / <br /> Surface restoration Hours � <br /> Site cteanu Hours <br /> Downspouts I drainage imp. Hours <br /> Materials Backwatervalve PerUnit OD, bd <br /> Grinder pum Per Unit <br /> Side sewer pipe up to B feet) Feet <br /> Imported Backfill Yards <br /> Surface Restoretion Malerials Lump <br /> to soil, rass seed concrete elc. sum <br /> Cover(irrigation box or load beadng Per Unit ' a� '� a�� �� <br /> cover <br /> RenWls Speci e ul ment Hour <br /> Fees Disposal fees by item Yards t�,p f7 ,O <br /> Delivery foes if not covered by labor <br /> EII ibleToWl $ � '� <br /> Other Costs Costs nol associaled with BWD,and ��x ,Z o� Q G <br /> not eli ible for rebate detail below <br /> � � <br /> Ineligible Total $ <br /> Total $ y0 •• <br /> �e� I <br /> �Z- '�rll � I <br /> Revised 9/03/2014 <br />