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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a templale for invoices submitted as pa•t of lhe Backwater <br />Prevention Device rebate program. [ither this iorm or your own invoice form with Ihe following line items can <br />be submiCed. This allows you to invoice your client according to your existing billing lemplate while allowing <br />city staft to idenGfy how cosis eligible for the Backwater Prevention Device Rebate were accrued. <br />Cnly labor and materials direcNy related to the insta!lation and function of a backwater prevenfion <br />device are eligi6le lor City rebate and therelore should 6e included on the upper half of thls form. <br />Additional costs may be added !o bottom o( the (om�. <br />St�ccP{;• �� <br />8usinessName:��/'n_;�'�� �F:��q�51�'P LicenseNumber.__��� <br />Dusiness Mailing Address: oS(r;L[n l.Gt �'Ir l'� r � «- • �/��+ �� � �" " � ' ""' <br />City State Zip <br />Phone:,.�v�"i�Lvy�C-,� Emaii:(�j �",1f17C(`1�� � �� '`� c1���cr2•'/: C't>7Y] <br />Revised 9/03/2014 <br />