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BACKWA�ER PiZEVEIVTION PROGRAM <br />� INVOICE COST BREAKDOWN <br />Please use lhis Invoice Cost Sreakdown as a template (or invoices submiiled as part of the Backwater <br />Prevention Device rebate program. Either this form or your own invoice furm v��ith the following line items can <br />be submitted. This aliov✓s you to invoice your dient according to your existing billing template while allowing <br />city staff to ?dentify how costs eligible for the Backwaler Prevention Device Rebate were accrued. <br />Only /abor and materials directly related to the instaflation and function of a backwaterprevention <br />device are eligible for City rebafe and therefore should 6e rr.cluded on the upper half of thls form. <br />Addifional cosls may be added lo bottom ol Hie fomi. �� �,� <br />Business Name:_,y�;(�'1'I��j � �- � �: ��'SL cense Number. _Q .S ' �� ^ <br />Business Mailing Address: vfl�n �.0 r/c v i �� �--• r—v� State Zi �� <br />City P <br />Phone:,,�7fv=�t�= �is.'i�` Email _Gi f�%�!'�_r�rn _��!)ii�t'ail�j.�Sa[ip,Cu: r Y".(: C"C2�1 <br />Materials <br />Rentals <br />Fee� <br />Othcr Costs <br />Total <br />AUminislration / managemeN nours <br />CCTV Inspeclion Hours <br />pWV Inslall Houts <br />Pipe replacement Hours <br />SuiTacc restoration Hours <br />Site cicanup � Hours <br />Downspouts 1 droinage imp. Hours <br />�ar.kwa�er valve Per Unil <br />Grinder pump Per Unil <br />Side sewer pipe (up to 8 fee[) � �eet <br />Imported f3ar.kfill Yards <br />Surfar.e Resloralion IJlaterialc Lump <br />_ lo soil,_grass seed, conaeie, etc. sum <br />Covcr (irrig�tion box or load bearing Per Unil <br />cover _ — <br />Specify equipment Nour _ <br />'Tr�__i� <br />Dispoaal fe�-.•. 6y dcm Ya�dS <br />Dr.livery fcr., il not rnvr.red by labor <br />Cosls nol associaled v�ith f3WD, and <br />not eligible tor rnbale detail belo� ___ <br />Revised 9/03/2C�1� <br />��� <br />S <br />