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BACKWA�ER PREVENTION PROGRAM <br />E INVOICE GOST BREAKDOWN <br />Please use this Invoice Cost Breakdovm as a tempiate for invoices suhmitted as part of the Back�vater <br />Prevention Device rebate program. Eitner this form or your own invoice form ���ith the foliovring line items can <br />be submitted. This allows you to invuice your cliant according to youi existing billing template �vhile allo�ving <br />cdy staff to identdy ho�:� costs r.ligibte for the Racke�ater Prevention Device Rebate �vere accrued. <br />Only labor and materials directly r•elated to the installation and function o7a backwater prevenfion <br />device are eligible lor Ciry rebate and therefore should be included on the upper half of this form. <br />l�ddrtional costs may be added fo boltom ol the form. <br />_I 5��� � �'`� ,//' <br />3usiness Name:�j����45{���UP License Numbe�. __[��j�_t_�_ _ __ <br />8usmess (�laifing Address: oZ(ct� LUf�'l E. ��,�L��l— -����= �-�•-�'-3 <br />City State Zip <br />Phone.��,��>••���'��----Email:�'i1L�%t�L,i!}�.Cir_a�1 ���[_1/ad.�lc�bccc.���'� <br />� Category <br />-- ---- ---�� —�--u--r.—=- -- � r_._� i <br />� Administration <br />I Labor _ _ <br />� <br />IM11ateriats _ <br />� ---- <br />I — <br />I� Rentals <br />� — — <br />ifces _^ <br />�-- -- ----- <br />Eliyible Total <br />Othcr Cosls <br />Ineligible Total <br />��� <br />Tota! <br />Ad:n�nistration / management <br />CGTV Inspection <br />BNN Install <br />Pipe replacemenl <br />Surface resloralion <br />Site cleanup <br />Dmvnsaouts / drainage imp. <br />Backwater valve <br />Grinder pump <br />Sitle sewer pipe (up ro 8(eet) <br />Imported Backfll _ <br />Sur(ace Restoration Materials <br />(tc�soil, grass seed, wncrete, eti <br />Cnver (irrigation box or load bearii <br />cover�__ _ <br />Sper.ify equipment _ r <br />Per Unit <br />Feei <br />Yards <br />Lump <br />Hour <br />Dispozal (r.ca 6y i�em __ _ __ `lams ' _. <br />Delivery tecs d not covered by lab�r _ _ <br />-C'('.11�_ , l rl �- ---- - --.. . _�Ti <br />Q=.. <br />Cosls not associated with BWD, and � <br />not eiigihle (or rebate_ detai! belou) _ I__- -- --1- - <br />Revised 9/0?/201 �; <br />$. <br />