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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this I�voice Cost Breakdown as a template for invoices su6mRted as paR oi the Backwater <br />Prevention Device rebate program. Either this form or your own invnice foi m with the following line items can <br />be submitled. This allows you to invoice your client according to yo�r existing biliing template while aliowing <br />city staH to identify how costs eligible for the Backwater Prevention Oevice Ret�ate were accrued. <br />On/y labor and materials directly ►elated to the installatlon and iunctfon ot a backwater prevention <br />device are eligJb/e lor Ctty rebate and therelore should be /ncluded on the upper half ot thls lorm. <br />Addifional cosfs may be added to bottom ol the lorm. <br />Business Name: <br />Business Mailing Address: � <br />Phone: L.1'L�: �t u �—�I Z � <br />Lebor <br />Fces <br />CCN Inspedion <br />BVYV Install <br />Pipe replacement <br />Sufiace restoration <br />Site cleanup <br />Downspouts / drainage im . <br />E-ckwa�^r valve <br />Grinder pur�p <br />Side sewer pipe (up ro B feet) <br />Imported Backfill <br />Surtace Resto2tion Matenals <br />__� soil grass seed, concrete, etc. <br />Cover (irrigalion Dox or load bearing <br />wver) <br />S ity equipment <br />�' <br />Disposal fees by item <br />Delivery fees if not covered by labor <br />Other Costs Costs not associated with BWD, and <br />not elinible for rebate (detail below) <br />Ineli ibte Total <br />Total <br />Revised 9/03i2014 <br />License Number. '�ti—UIvf4X Cr// �rJ <br />Hours <br />Haurs <br />Hours <br />Hours <br />Hours <br />Yards <br />� <br />