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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Piease use this Invoice Cost Breakdown as a templale for invoices submitted as part of the Backwater <br />Prevention Device reDate program. Either this fortn or your own invoice form wilh the following line items cen <br />be submitted. This allows you to invoice your c1ieM according to your existing billing template while allowing <br />city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only labor and materlals dircctly relafed to the installation and function o/ a bsckwafer preventlon <br />device are eliglble for City rebate and therefo�e should be incfuded on the upper hslf o1 thls form. <br />Addicional cosfs may be added to boftom ol the lorm. <br />Business Name: <br />Business Mailing Address: <br />LicenseNumher. {4V4�U u%�6l,(f�_ <br />Zip <br />Phone� �ili� 11'�`�—a IZ3 Emai1: o`h`1—P('�rn�oi�^q �L�-��1(�' (5M1t+1 � icr� <br />Revised 9/03/2014 <br />� <br />