Laserfiche WebLink
�A�a(V�IA�'ER PR�VENTBON �Rf�SGRANI <br />ilN�'OIC� COSi �REAKDOV4►N <br />Piease use this Invoice Cust Breakdown as a template for invoices submitted as part of the Bacic�vater <br />Prevention Device rebate program. Either this form or your ow� invoice form with the folluwing line ilems can <br />be submitted. This allows you to invofoe your client eccording to your existing billing template whle allowinn <br />city sfaff to identify how cosls eligible for the Backwater Pcevention Device Rebete �vere accrued. <br />Only la6or and materials direcdy related (o Phe insPaflation and func6on of a baekwater prpvention <br />sleviee a�e eligil�le for City rebate end tRerefore shoufd be 6ncluded on the upFer ha(f of tlils Iorm. <br />Addifional costs may be added fo boftom of the lorm. <br />BusinessName: ! G� � �'l��.(C Licenset�umber. LA-/i-f-'��i�'ntiPr�t _ <br />Business Mailing Address: �%nl/ /�/�SfZU'ci�r'� Y%�/�=� �--�i-el� (nh`�' g,1 L�Y� <br />_ _ ,,, , City _ State^ � Zip <br />Phone: �) ` ���y'—U!Z � <br />FyLI <br />Revised 9/03/2014 <br />