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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this I�voice Cost Breakdown as a template tur invoices submitted as part oF thb Backwater <br />Prevention Device rebate program. Either this form or your own invoice form with the following line items can <br />be Submined. Thfs allows you to invoice your client :���: -ding to your existing bil�ing template while allowing <br />city staff to identify how costs eligible for the Bac;.v•stc : revention Device Rebate were accrued. <br />On/y labor and materials direetJy related tn the lnstaflation and hrncHon of a backwater pievenfion <br />devlce are ellgible for City iebate and fherefore sbou/d be incladed on the upper hal( of thls form. <br />Additional custs may be added to boffom of the fonn. <br />�� 1.�-C� <br />8usiness Name:, Nri i� v� �l�Qr•S��e��nse Number: ��i:���i`.�� <br />Business Mailing Address: bVcY.(c% l.F�!"►cVt uK- �(/�w �� '"" <br />Ci State Zip <br />•�.�• ..:• Is � �� � .• �...-- .,— . « �)Ii <br />P.evised 9/03/2014 <br />