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- BACKWATER PREVENTION PROGRAM <br /> �MVOICE COST BREAK�IOWN <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as part ot the Backwater <br /> Prevention Devicp rebate program. Either this form or your own invoice form with the follo�,ving line items can <br /> be submitted.T1iis allows you to invoice your client according to your exisling billing templatc while allowing <br /> city staft to identify how cosls eligible for the Backwater Prevenlion Device Re6ate were accru�d. <br /> Only lab�r and materials direcfly related to the installatian and/unction of e baekwafer prevention <br /> device are eligible/or City rebate and therefore shoufd be included on the cpper hall 01 ihi;:/orm. <br /> Adddional cosfs may be addad to bottom ol the form. <br /> Business Name:�1� QI Ui��b N'Q �L=� _License Numher. ,474-��✓��'Cf7/ ��� <br /> Business Maifing Address: �Cn l l ��� 'fYI.+�Zt.f'YL0. F�'� �'V�I�� 'vi.��l `'� �2�c": <br /> City State Zip <br /> Phone:��Z) - � P:"�-L'l2?� EmaiL G«- l�r� !�lf2q C�C- ��l(� ('�r�R-rL •CG t�"'� <br /> Cat o Descri lion Units Quanti Rate Total <br /> Adminisiration Adminislration/managemenl Hours <br /> Labor CCN Inspection Hours <br /> BVYV Install Hours (pCo� � �a <br /> Pipe replacement Hours <br /> Surface restoralion Hours <br /> Site cleanup Hours <br /> Downspouls/drainage imp. Hours <br /> Materials Backwater valve Per Unit 1 Zyl. Zz� . <br /> Grindcr pump Per Unit <br /> Side sewer pipe(up l0 8 feel) Feet <br /> Imported BacMill Yards <br /> Surface Reslorafion Malerials Lump <br /> to soil,grass seed,concrele,elc. sum <br /> Cover(irtigalion box or load bearing Per Unit <br /> cover <br /> Rentals Speciry e uipment Hour <br /> Fees Disposal fees by item Yards <br /> Delivery fees if ncl covered by labor <br /> Eli ibie Total $ <br /> Other Costs Costs not associated with BWD,anJ <br /> not cii i61e for rebate detail below <br /> • � , ' O � <br /> r� <br /> - - -��- ° y <br /> � �� <br /> - - .� <br /> Ineligi6�eToYa� �^.� $ � � <br /> Totai $ ��v' <br /> ,� OC� <br /> Revised9/03/2014 " �_ (�_ (� <br />