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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Ploase use this Invoice Cost Breakdown as a template for invoices submitted as part of the Back�vater <br /> Prevenlion Device rebate program. [ither Ihis form or your own invoice form vfith ihe foilo�ving line items can <br /> be submitted. This a�loe��s you to invoice your client acwrding to ycur existing billing template vahile allowing <br /> city staff to identi(y hov.�costs eligible for the R�r.kviater Prevention Device Rebale �vere accrued. <br /> Only labor and materials directly related to the installa;ion and lunction of a backwater prevenfion <br /> device are eliglble for City re6ate and therefore sf�oufd be included on the upper hall of this form. <br /> Additional costs may be added fo bottom of the (ortn. �� <br /> SW�u;� <br /> 3usiness Name:�;�l'�Pri�___�:l��.�L_L��.'-:?,r�P. Licensc Number: _Q5�_���___ <br /> Business Mailing Address: `G���c LGc c 't ��. r � —����`3�'`3 <br /> City State Zip <br /> Phone:��a�"1��v=�d���'-� Emai�_('1l1-�:r�11'-�-�cz�� �� tL.S:ti�.S�:iC'l=�'�7 <br /> ��Cate2ory_( p� escri tiP on Units Quanti Rate Total � <br /> i Administration ! Adndni;Ua;ion I managemenl Hours <br /> � Labor �CGTV Inspeclion _ Hours �___ � <br /> � � 84W Install Hours <br /> I _ � pip2 replacement Hours _ — <br /> �wface resroration Hours _ _� '� ___i <br /> Site cleanup Hours — ' <br /> Dnrmspouts/drainac�e imp Hou�s _ _ --� <br /> Pcr Unil 'f +� ���'s � �. <br /> Materials __ Backwater valve __ - � <br /> � Grinder pump Per Unit �-�-��, _ _ <br /> �-- Side sewer pipe(up to 8 feeq Feet �< <� �.='(�dv_ _� <br /> Imported Backfill __ Yards _ <br /> i� Surtace Restoration M1�1a�erials � Lump ,�,� — �/-� <br /> to soit, rass seetl,c.oncrete,etc. ___sum ���`"' <br /> � 9--—------� <br /> Cover(irriga�lon box or load hearing Per Unit <br /> cover) - -— - — --�_'_-L�-- 1 a <br /> Rentals Specify equipment Hour <br /> --- — �o_ a — <br /> : ____ _i�n���_t� ---- <br /> Fces DiSposal fees by ilem___ Yardc ____ <br /> � - ---- -- -- -- _ . _aaa7_-- <br /> _ pelivery tecs i(not covered by labor __ -- -_---_- -- - - ---�.. <br /> f-- - __ -- — __ - - -_-- 5 - <br /> fEli ible ToWI ---- --- a -- --- <br /> � o��or Costs Costs nol associated v�ilh BWD,and ' I ,l <br /> not eliqible lor rebate (delail_beloer)_ _� — - — —� <br /> �--- � - -- � �- - - i -- --- ---- --� — \r�" <br /> L _`_ — — —. __�� ----- -���-��� <br /> �— ------ ;5� a � , _ <br /> — �--� <br /> � Ineligible Total 5 � <br /> ,�tal --- - -- - — -- 5 �1 _ <br /> Rcvised 9/03/2014 <br />