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BACKWATE►2 f�REVENTION PROGRAM <br />INVOICE �OST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices eubmitted as paA of the Backwater <br />Prevention Device rebate program. Either this form or your own invoice fortn with the following line items can <br />be submilted. This allows you to invoice your Gient according to your existing billing template while allowing <br />city staHto identif� how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only la6or and materials dlrecNy related to the insfallafion and funcfion of a backwaterpreventlon <br />device are eligible for City re6ate and therefore should be included on the upper half of this form. ,s� <br />Additional costs may be added to bottom of the form. `��P�(G� 2�# 1 <br />Business Name:l"`�S��IUT�.�r: i�Mc�tC\ �� License Number: � S'$ O��� � �� �X'� j) <br />�7 n � � � -�1; � � �'-1 � �:1 /� �/ <br />Business Mailing Address: T r� �� .�� �'J• C. Q�rli.`ti'i�S w�� ' 1.5�',�C� <br />� // � 'J � <br />Phone: �lL' "�i G'S r`"1���> <br />Cate o Descri tion Units Quanti Rate Total <br />Adminlshation AdministrationJmanagement Hours <br />Labor CCN In ection Hours '' �!u �, '� (l; <br />BWV Install Hours S, ., � <br />Pipe re lacement Houre <br />Surface restoration Hours <br />Site cleanup Hours <br />Downs outs / drelnage lmp. Hours <br />Materials Backwatervalve PerUnit t,�`J„' , <br />Grinder ump Per Unit <br />Side sewer pipe (up to 8 feet Feet <br />Imported Backfiil Yards <br />Suriace Restoration Materials Lump <br />to soil, rass seed concrete etc. sum <br />Cover (irtigation box or load beariog Per Unit f 1 � <br />cover I ��j,L� ..r7a�. <br />Rentats S eci uipment Hour <br />Fees Disposal fees b item Yaids ,�.; ic>1 .x_'C�+h , E7Cl <br />Delivery fees if not covered by labor <br />Eli Ible Tofal $ :,^ ' ) C�'; <br />Other Costs Costs not associated with BWD, and <br />nol eli ihle for rebate detail batow <br />ineligible Total $ <br />Total $ C"�i {.Cx� <br />Revised 9/03/2014 <br />