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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdo�m as a template for invoices su6mitted as part ot the Backwater <br /> Prevention Device rebate program. Either lhis form or your own invoice form with the following line items can <br /> be submitted. This allows you lo imroice your client according to your existing billing template while ailowing <br /> city s1aH to identity how costs eligibte(or the Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials dfrectly related to fhe inslallafion and IuncHon of a backwater prevention <br /> device are eligi6le lor l;ity rebate and fhe.elore shoufd be included on the upper haH o/fhis Iorm. <br /> Additional costs may be added to bottom ol rne fam. � <br /> BusinessName:���Un•+bl!'� �[ L LicenseNumber. <}9'����'L�' !57/ �� <br /> Busi��ess Mailing Address:�C[iL� _ I/�� t'CU�'[L!'i'lA �IL �Va'ii�t-`�— 'vi.�'1J1 `� �2��`, <br /> City State Zip <br /> Phone:/1�) ' °l Q•�—012 j Email: /i�:-/�l�na !oi/2q �r_ C.. .��1-7�� ('�iaFfirL • L t�^''• <br /> . <br /> Calegory_ _ Descriplion __ Units Ouantit Rate Total <br /> Administration Administralion/mana9emeN� Hours _ � __ ___ <br /> � Labor CCN Inspeclion — Hours _ _ ,JGO '- _ __ <br /> BVJV InsWll Hours �'2�7 <br /> Pipe replacemenl Hours <br /> � Surlace restoralion Hours �D � <br /> I Sile cleanup Hours � O O � <br /> Downspouts/drainage imp. Hours L7� I <br /> Malerials Bacfavaler valve Per Unil O � _ _� <br /> Grinder pump Per Unit _ i <br /> Side sewer pipe(up�0 8(ee�) ^ Feel _ <br /> ImpoAed Backfill Yards / O O - <br /> Surface Restoration Malerials Lump <br /> _ _ 1�soii,grass seed,concrete,elc.L sum �� � __ _ <br /> Cover(imga6on box or load heanng Per Unit <br /> covcr�-__-- _- <br /> � Renlals __ Specify equipmenl Hour _ <br /> �- - <br /> Fecs __ Disposal(ees�iy ilem Yards <br /> _ — .-- i Ilvery fces il nol covered by labor- ---— - _ - �---- -- -- - - --- <br /> Q � � / 5--- <br /> Eli IbleTatol- -- " `- ✓ U-. �----�--- -- - �- - . ....__. <br /> 1 <br /> Costs not associa�ed wdh BWD, and � <br /> Othcr Cosls i <br /> - - ----- n�t cli ibg le lor rebate_(detad below)--_--��; ��.��' �'j '..---�. <br /> - - 1`' <br /> --------- ,` --(- - --'— � <br /> -------- -U F'--�-`).- f _�•�i1�.ut � — --- -- �_— <br /> ._ __ — --___— `^�.C�_____- -�_ _— _ __�.��_�-___. _._ <br /> � C� - - \e-�-'' v�--- - -- --- - - <br /> -----------— v -+--=- �- ---- -- --- <br /> - -- -- — - <br /> Ineligible Total �nit�"� �' S O <br /> Tota1-- -- - --t�,.�, � ` __ 5�J� <br /> r � � � � � 3 <br /> I � <br /> Revised 9iO3/2014 <br />