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i <br /> �A�KVVA�'I�R P6�EiiENT90fV PROGRAfVI <br /> ; <br /> �h��/OIC� CO�l' �REA{C�OVVN ; <br /> � <br /> Ptease use this Invoice Cost Breakdown as a templale for invoices submitted as part of the Backwater I <br /> PreveMion Device rehate program. Either this form or your own invoice form with the following line items c.sn � <br /> �e submitted. This allows you to invoice your client according to your existing billing template wh;le allowing i <br /> city staff to identify how costs eligible for the Backwater Prevenfion Device Rebate were accrued. I <br /> � <br /> nnty labor and materials directly re6vte�Fo[i�e installation and funcPion of a backsvaterFreventlon <br /> devies are ellgibfe 9or Ciry eebate and there%re should be included on the upper half ol this IQrm. <br /> Additronnl cosrs may t�e added to bottom ol the lorm. i <br /> Dusiness Name:�' v a � _ License Number. � ��P �l������ � <br /> I <br /> Business Mailing Address: �/� ( Ul�l d✓Q-I'L�- ,F}� �;-y� (nI�-_ __ _ � <br /> I + c� � Ci(yI � State Zip ; <br /> Phone: ��� �-lo �—��Z�, Email:�P � •r»IolVl" l.�C��'��Nrh�m 14ti���lp'�— � <br /> Catc o Descri tfon Units Ouontit Ratc Total ` <br /> Administration Adminislrationlmanagement Hours j <br /> Labor CCN lnspeclion Hours ��O � ; <br /> BWV Install Hours •t . � C? <br /> Pipe replacement Hours _t_ 5 U { <br /> Surface restoralion Hours �Q ' <br /> Site cleanup Hours _ �� � <br /> Downspouts I drainage imp. Hours <br /> Materinls Backwater valve Per Unil � <br /> Grinder pump Per Unit <br /> Side sewer pipe(up lo B feeq Feet � <br /> Imported Backfill Yards � <br /> SuAace Restoration Materiais Lump <br /> to soil, rass seetl, concrete, etc) swn i <br /> Cover(irrigation box or load bearinc� Per Unil / <br /> cover � ��J <br /> Rentals Specify equipment Hour _ <br /> V Yv.,�%T' '� <br /> Fces __ Disposal fees by ilem _ Yards , __ , <br /> ------ � <br /> _ Delivery fees if not covered by labar I <br /> - - - - <br /> - -� - --- ---- - ,� ; <br /> [li ible Total --- - - — <br /> V ____ $. <br /> Othcr Costs Costs not associated wilh OWD, and � <br /> not eliqible lor rebale(detail betow __ _ <br /> � -- --_... .. _ i <br /> V <br /> � <br /> Incilgihlc ToWI - - - � �jl - ' <br /> rotaf ��� . T ,4 , <br /> - - - - -- �_ - �-=?���- - <br /> Rr.vised 9/03/2014 � <br />