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BACKWATER PREVENTION PROGRAM <br />INVOlCE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a templale fur invoicas aubmitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your own invoice form with the follov�ing line items can <br />be submitted. This allows vou to invoice your client according to your existing billing te;nplate while allowing <br />city staff to identify how costs eligible for the 9ackv�ater PreveNion Device Rebate �ier� acc� ued. <br />Only labor and materials directly related to the lnsta!lation and function of a backwater prevention <br />device are eliglble for Ciry rebate and there!ore should be included on the upper i�alf of this /orm. <br />Additional costs may bo added to bottom o( the lortn. <br />S�,�tc' � �.C.G <br />Business Name:���'�-��r�� G.�-Srr�C' License Number. _���� -- <br />Business Niading Address: cS(Gc-lc_LGt rh 6't i I«� ��C�7 l.Jn i<<�(.;,� <br />Cily State Zip <br />Phone:��-�/v •-�'`S:�l Email_G �i -<p�� � '.t�P���r7'�: Cc5YY1 <br />Revised 9/03/20f4 <br />