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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 lhe Backwaler <br />,; Prevention Device rebate program. [ither this torm or your own invoice form evith the foiloveing line items can <br />be submitled. This allows ynu to invoice your client according to your existing billing template �vhile ailowing <br />city slaff to identify hov+ cosis eligible ior the Backwater PrevenGon Device Rebate were accrued. <br />Onlylabor and materials diroctly relafed fo ih ^ installation and function of a bacFnvaterprevention <br />device are efigible (or City rn,bate and therefore shouid be induded on the upper haif of this form. <br />Addifional costs may 6e added fo 6ottom of the (o�m. <br />���_� � ��.d,-, ' e`5l�.icense tv ber. _�j�J� `` ",'] <br />Business Name: � <br />Business Mailing Address: of(c�lv L.F�rl�t� �-1 ��-• ��'�� l,l.ir, i.sdt �.� <br />City State Zip <br />Phone:,��'. L1•-,�_y'�t Email:(�i�)n ��i�_in �� ����11d S�riP�P,��'/:C'c+719 <br />Revised °/03/201A <br />