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BACKWA�'ER PREVENTION PROGRAM <br /> ;'� � INVOICE COST BREl�KDOWN <br /> Please use ihis Invoice Cost Breakdov+n as a tempiate for invoices submitted as pari of tlie Backwater <br /> Prevention Device rebate prograrn. Either this form or your own invoice form �vith the foliov�ing line items can <br /> �c submitted. This allov�s you lo invoice your client according to your exisling billing template while allov✓ing <br /> ciry staH to idenhfy how costs eligible for the Backv�ater Prevention Device Rebate vdere accrued. <br /> Only lahor and rnaterials dirr�ctly related to the installation and function of a backwater provention <br /> device are eliglble for Ciry rebate and there(ore should be incfuded on the upper half of this form. <br /> Adddiona!costs rnay be added fo boffom ot fhe Iorm. <br /> /' 5°Ji;cl'�i�''�Ci V <br /> 9usiness Name;H�l�j-j(.�I�_ ' �- .-- �LP License ��umber. _�S� S �' <br /> Dusiness Nailing Address: c��-� LCL('��['t C.J�.1�'��'� �-��/9 �����3 <br /> City State Zip <br /> Phone:3L�Xp_�1_�_s�.� Email:�_��� rt�/'�tz�� � } defiYnc'�: C•c>7Y1 <br /> � Catcg� Doscri tion Units Quanti Ralc Total <br /> � Administration Administration/manapement Hours <br /> Labor CCTV Inspection __ Hours �� <br /> gWV histall Haurs � <br /> Pipe replacement Hours _ <br /> Surface resloralion Hours <br /> - - — —i <br /> Sita cleanup _ Hours { <br /> � Downspouts I drainage imp. Hours _ ; <br /> i Materlals Backwater valve _ Per Unit �iC��a �,� ,�.�i S _� <br /> Grinder pump Per Unit ! <br /> Side sewer pipe(up to 8 feet) _ Feet �� _� <br /> Imported Backfill Yards � <br /> Surface Restoralion Materials Lump <br /> _to soll arass seed,concrete,etc. sum "J(7 _a�_ <br /> Cover(irrigation box or load bcanng Pcr Unil <br /> cover ��--�� - <br /> Rentals Spec'rfy equipmenl Hour <br /> �_ YV1.f4L�—��' -- � ---��-- .. <br /> i <br /> �-7 � <br /> f_Fces Disposalfecsbyitem Yords _ _r}__J_.� <br /> _ Dclivr.ry Ices if not cnvr.red hy I�hor _� <br /> Eli ibleTolal ---- -� -J-- --- - � - �� <br /> Othcr Costs CoSis not associ�lled v�ith OWD, and <br /> not eliqible for rebate(delail beiow) _ _ — __ <br /> .. �� Ccv� ?t r.k.r <br /> — ---- �w T i <br /> Ak� (C� <br /> _��I l t; IL��,tYa I i <br /> IneligibleTotal $ 3 ZI�iS <br /> Total ------------- -- —J�- _S o'j .a����J <br /> Rcvised 9/03/2014 <br />