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BACKUIiA�ER PEtEVENTI�JN PROGRA{I!'i <br /> � INVOICE COST BREAKDOWN <br /> Please use thi: Invoice Cost Breakdown as a templato ior invoices submiL'^d as part oi the Backwaler <br /> Prevention Device rebate program. [ilher this torm or your ovan invoice fo�m with thQ following line items can <br /> be subm�tled. This allotivs you to invoice your client according to your existing billing template while allov+ing <br /> ciry staH to idenhiy ho�v costs eligible for the Backv�ater Prevention Device Rebate were accrued. <br /> Only labor and materials directly related to the installation and function of a backwater prevention <br /> devJce are eligi6fe for Ciry rebate and therefore should be included on the upper half of this form. <br /> Additional costs may be added to bottom ol the fom�. <br /> p r u-� <br /> 3usiness Name;�-1�q.Lc�l.�-�- ' L�1�L ce se Number. _�5�� ��_— <br /> Business �ailing Address: c���c: ��f��l� f i����'��'-� r���� ��"� ���-'-'3— � <br /> City State Zip <br /> Phone:,`��(v'�C� ._ �'`.��. Email: : �� iCi��� cri �i,c�br'1����'�1 <br /> rI�Calego Descri tion Units Quantit Rate Total <br /> � Administration Adminislration I managemenl Hours __ <br /> ' -- - Hours <br /> j Lahor CCTV Inspection __ __�_____: �� =��-Q <br /> � BNN Install Hours <br /> � Pipe replacemenl Hours � <br /> rSurface restoration _ Hours _ <br /> t Sile cleanup Hours <br /> � Do��mspouts 1 drainac�e imp. Hours <br /> PerUni! �'�j�11 -�.(„ � <br /> i Materials t3ackwater valve _ -- <br /> Grindcr pump Per Unit <br /> L Side see�er pipe(up to 8 feet) Feet __ �� - %' c��.� <br /> k _ Imported Backfill Yards _ _ _ __ __,____ <br /> Sur`ace Resloralion tJatcrials Lump �U � <br /> _ _�oQ soil,yrass sr.ed, concrele, elc.L sum . �_ � <br /> Cover(irrigation box or load h�aring Per Unit <br /> cover _ �_- � --�`� — <br /> � Rentals Spoci(y enuipmenl Hour ____ _ _ __ <br /> -- �� I�l[iC—�-� -- -�-- —1'`�i-- ,� — <br /> Fces Dispos�l trte•s by ilem ` Yards _ __ � � �� <br /> ---- -- — , -r.��— <br /> ---'-------- --- <br /> --- -- - <br /> - Delivery fees if nol covared by labor ____ ___ ____._ _-- ._ __ <br /> ------ - -._. �-�-- ----- — <br /> - - ------ � — --- _ . )� <br /> Eli IUIe Total � � �� � <br /> Othcr Costs Cosls no[associated wilh DWD, and <br /> i� not eligihlc tor re6ate_delail belo�v1, __ ________ -- <br /> - - � tv��� C�,� s�ei�� <br /> I --_- - --- �.�-�� <br /> �-- <br /> (.�i.k •U/.�. <br /> � ��y���i <br /> �neligible Total f/ S �/�} � �" <br /> LTotal - - �----- <br /> Revised 9/03/2014 <br />