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�A,CKINAT'ER PREVENTIOId PROGRAM <br />IIVVOICE COST �REAKDOWN <br />Please use this Invoice Cost Breakdown as a templale for invoices submitted as parl of ihe Backwater <br />Prevention Device rebate program. Either this form or your own invoice form wilh the following line items can <br />be submitted. This allows you to invoice your client according io your existing billing template while allowing <br />city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Onty labor and materials directly related to the fnstallation ai�d /unction o/ a backwater prevenfion <br />device are eligible /or City rebatc and thcrelore should be inciuded on the upper hal/ of thls form. <br />Additional cosfs may be added lo bofiom of fhe l�rm. <br />Business Name: � PI� m�. � License Number: �P��1�0/i r�.� <br />Business Mailing Address: ��l �/li �'ctV�INCa f}"!� �-i l� d2`� <br />City Sta Zip <br />Phone:�l-��q'G/�3 Email: fi�-P��ivl�ll't�,t�f�-�f�'�Gir�7/h��L�n'� <br />Rentals <br />Fces <br />Elit�iblc Total <br />Othcr Costs <br />Inuligib� lo Totnl <br />Total__ __ <br />Adminislration ! ma <br />CCN Inspection <br />BWV Install _ <br />Pipe repiacemenl <br />SuAace resloration <br />Site cieanup <br />Downsoouls I drain <br />Grinder pump <br />Side sewer pipe (up to I <br />Impoded Backfill <br />Surtace Restoration Ms <br />(top soii, grass seed, cc <br />Cover (irrigation box or <br />cover) <br />S ecity equipmenl <br />�."_'_�� " <br />bisnosal fees bv Ilem <br />Uelivery fees if not covered by labor <br />Costs no� t associated with BWD, and <br />not cliaible for rehate (detail bclow) <br />Revised 9/03/2D 14 <br />Hours <br />Hours <br />Per Unit <br />Per Unil <br />Yards <br />Lump <br />sum <br />Per Unit <br />Rate <br />�i O <br />�r I y5 <br />/ I �5 <br />— — � �: <br />-- ' -- ^� �--I-$ i^��� <br />c—� �- <br />0 <br />