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BACKVIIA�'ER PREVEIVTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a tempiate for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your own invoice form with the following line items can <br />be submitted. This aliows you to invoice your clienl according to your existing billing femplate while allovring <br />city staft to identify how cosis eligible for ihe Backwater PreOention Device Rebate were accrued. <br />Only labor and mate�ials directly related to the ins[allation and function of a backwater prevention <br />device are eligible for Ciry rebate and therefore should be included on the upper half oF this form. <br />Additiona! costs may be added to bottorn o( the form. �� <br />5���' ; ��c� <br />Business Name;�jliz!�� ' ' �- '�, • c3 License Number. ��7�'"7� �" '_�ti_ <br />Business Mailing Address: oSlGuc �u! �� 1���-• ' �}v � State <br />Pho�ie:,��'•�fc��� EmaiL•i��lY�%��nnv�r'��czn4�,11�+� riii.i ;_i �ri�b�c�s2"� C•v7Yl <br />, <br />Revised 9/03/2014 <br />