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� <br />BACKWATER PREVENYION PROGRAM <br />INVOICE COST BREAKDOWN <br />Plezse use this Invoice Cost Breakdown as a template for invoices �submitled as part of the 8ackwater <br />Prevention Device rebate program. Either this form or your own invoice torm with the fNlowing line i;ems can <br />be submitled. This allows you to invoice your clienl according lo your existing billing template while allowing <br />city staH to identity how costs eligible for the Backwaler Prevention Device Rebate were accrued. <br />Only labor an� materials direcGy related to the insta/lation and function of a b e� If o�his formn <br />device are eligible for Ciry rebate and therefore should be included on the upp <br />Additional costs may be added to bottom of the (orm. � <br />5�'Lu i <br />Business Name;%�r}ry]L'�_C���'� �'�-rt�-'-<, ;�P License Number. _Q��-- <br />Business Mailing Address: bt(�uc L.F�' r/c l'� CJ «• I-1L�' �'•� '."` ' l� <br />City State Zip <br />Phore:�Y -�Gft�•-'yY?�'�. _Email:t;.^ r)n Nr-�nn��/1�����j S';r3r�Ca-r2°!' C�� <br />Revised 9/03/2014 <br />