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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your own invoice form with the following line items can <br />be submitted. This allows you to Invoice your anent according to your existing billing template while allowing <br />city staff to Identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only labor and materials directly related to the Installation and function of a backweerprevention <br />device one eligible for City rebate and therefore should be Included on the upper half of this form. <br />Additional costs may be added to bottom of the form. <br />Business Name: zfzd1b &ML License Number: /9D•✓� <br />Business Mailing Address: 1%00/��Q,7 //F_ �'tigy Vic La <br />City State Zip <br />Phone' <br />Category <br />Description <br />Units <br />Quantity <br />Rate <br />Total <br />Administntlon <br />Administration l management <br />Hours <br />Labor <br />CCTV Inspection <br />Hours <br />BWV Instill <br />Pipe re laoemenl <br />Hours <br />Sudaoe restoration <br />Hours <br />Site deanup <br />Hours <br />Downspouts I drainage Imp. <br />Hours <br />Materials <br />Backwater vatvo <br />Per Unh <br />Grinder pump <br />Per Unit <br />Side sewer pipe (up to 8 feet) <br />Feel <br />Imported Seckfill <br />Yards <br />Surface Restoration Materials <br />(top soil, aress seed. conotete. etc. <br />Lump <br />sum <br />Cover (infgation box or load bearing <br />cover <br />Per Unit <br />kentals <br />SpociN.equipment <br />Hour <br />r <br />Foos <br />Disposal lees by item <br />Yards <br />Delivea lees it not covered by labor <br />EII ible Total <br />_ car �r Twee ! <br />rYiX% <br />$ <br />Other Costs <br />Costs not associated with BLVD. and <br />not eligible for rebate 'detail below <br />Ineligible Total <br />S <br />Total <br />Revised RMN2014 <br />