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BACKWATER PREVENTION PROGRAM <br /> � INVOICE COST BREAKDOWN <br /> Please use lhis Invoice Cost Breakdown as a tempiate(or invoices submitted as part ot the Backvaater <br /> Prevention Device rebate program. Either this form or your own invoice form with the following line items can <br /> be submitted. This allows you to invoice your ciienl according to your existing billing iemplate while allowing <br /> city sfafl to identify how costs eligible for ihe Backv�aler Prevention Device Rebate were accrued. <br /> Only labor and materials directly related to the instal/ation and function of a backwater prevenfion <br /> device are eiigibfe lor Ciry rebate and therefore should 6e incfuded on the upper half of this (orm. <br /> Additional costs may be added to bottom o(fhe tonn. <br /> � 5�'�'��i�/ _�c��,�-�`1"� <br /> Business Name:.r�Pn�s��'� �[?��'}�S+r��' License Number. � <br /> eusiness Mailing Address: o'ZG:�-(c Lu.r��vt �E--• ' T�' � �.r n ���c�'� <br /> City utate Zip <br /> � Phone��c'xin --:X:�'� _ Email:_ ,) �y:r���n_��/}�i�1.3Lk�S,c��-�C(: C'c� <br /> Cate o Descri tion Units Quanti Rate Total <br /> Administration Administration/managernenl Hours <br /> Labor CC7V Ir.spection Hours <br /> gWV Install Hours <br /> pipe replacement Hours <br /> Sur(ace resloralion Hours <br /> Sile cleanup Hours <br /> Dotivnspouls/drainage imp. Hou�s <br /> Materlals Backwaler valve Per Unit __�1- .I . <br /> Grinder pump Per Unit <br /> Side se���er pipe(up l0 8 feet) <br /> Feet �� �' �� <br /> �mported Backfill Yards <br /> Surtace Restoralion Materials Lump � <br /> (lop soil arass seed,concrete,elc.L sum ? �� <br /> Cover(irrigation box or load bearing Per Unii � a L� <br /> cover <br /> Rentals Specify equipment Hour _ <br /> —�-- - <br /> Fecs Disposal tr.rs by ilem Yards _ _p� C�� <br /> Delivery fers if not covered 6y labor <br /> Eli ible Total � � � $ � <br /> Othcr Costs Cosis not associaled with BWD,and <br /> not eligible(or rebate detail betow <br /> �)�t. � <br /> N� . <br /> Ineligibie Total � ����� 4 � ! <br /> Total �� � <br /> Revised 9/03/2014 <br />