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L BACKWATER PREVEI�TION PF�GRAM <br />INVOICE COST BREAKDOWN <br />Please use lhis Invoice Cosl Breakdown as a lemplate for invoices submitted as part of the Backwater <br />Preven6on Device rebate program. Eifher this (orm or your own invoice form with the following line items ca� <br />be si�bmicted. This allows you to invoice your client according to your existing billing templale wh�le allowing <br />city statf to idenUfy how costs eligible for lhe Backwater Prevention Devica Rebate wete accrued. <br />Onty Isbvr end materiaJs direcHy related fo fhe insfelletlon and IuncUon o/a backwatsr pmvention <br />devke �►e Nigfble lor City rebate arrd therelore sfrould be N�cluded on the upper Aall of fhls form. <br />Business Name: �A-l�lUn�bin s i i_� License Number.� UL� �/�PQ <br />- - - • - .— � . ,, o ,�, .. Q <br />Business Mailing Address: <br />Zip <br />Phone:�l�{-'uR�i'b�� Email: �/i-�I�w�bt LL�- �-I��°'��'!'WILL(3Y✓\ <br />Revised 9/03/2014 <br />