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BACKWATER PREVENTION PIROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this invoice Cost Breakdown a3s a lemplate for invoices submitted as part of the Backwater <br /> Prevention Device rebate piogram. Either this form or your ovm invoice form vdilh the following line items can <br /> be submitted. This allow; you to invoice ycur client according lo your existing billing template while allowing <br /> ciry staff to ide�tify how costs eligible for the Backwater Preverdion Device Rebate were accrued. <br /> Only labor and materials directly related to the inscallafion and function of a backwater prevention <br /> device are eligible for City rebate and fherefore should be included on the upper half of this form. <br /> Additional costs may be added to bottom o(the (orm. <br /> Business Name: � � I✓Lu .�.LL _ Li�ense Number. �I-/g-N�U I �9�l�__ <br /> �J <br /> Business Mailing Address: �Qf.L�l.5�Va1�t. !�� -�.-1'-EI�T L.J�- 9�g <br /> /I City State� Zip <br /> Phone: �� — `1 �9`02 � Email: /97���w���o/�'�9 �l( .;L�( ""�n�/hL-.C�`�'� <br /> Cate o Descri lion Units Quantit Rate Total —� <br /> Administration Administration I managemen[ Hours <br /> Labor CCTV Inspeclion Hours p0 <br /> 814N Install Hours �`j p0 _ <br /> Pipe replacement Hours "] <br /> Suriace reslora�ion Hours � <br /> Sile cleanup Hours �'jZ� <br /> Downspouts I drainage imp. Hours <br /> Materials Backwaler valve Per Unit <br /> Grinder pump Per Unil <br /> Side sewer pipe(up l0 8 teet Feet <br /> Imported Backfill Yards %/p <br /> Surtace Restoralion Materials Lump <br /> to soil, rass seed, concrete, e�c, sum <br /> Cover(irrigalion box or toad bearing Per Unit <br /> cover <br /> Rentals Speci(yequipment Hour <br /> - �1'f� — �P <br /> Fees Disposal tees by ilem Yards <br /> Delivery fees if nol covered by labor <br /> Eli ible Total �� <br /> O[her Costs Costs not associated wilh BWD,and �� � •2� �6 <br /> nol eli ihle for rebale delail below J <br /> --- _, 7� �� <br /> Ineligible Total $ <br /> Total � _ � � <br /> Revised 9/03/20I4 <br />