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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this I�voice Cost Breakdown as a template tor invoices submitted as part of the Backwater <br />Prevention Device rebate progtam. Either this form or your own invoice (onn with the (ollowing Bne items can <br />be submitted. This allows you to invoice your client according to your existing billing template while allowing <br />city statf to identify how costs eligible for the Backwater Prevenfion Device Rebate were accnied. <br />Only labor and materials dircctfy rNafed to fhe installafion and Iu�tion ol a baekwafcr preventfon <br />devlee a� eligible Ibr Clfy rcbate and fhereloro should be incfuded on the upper haN o/ Mls Iorm. <br />Addifional costs may be added fo bottom ol fhe lorm. <br />Business Name: �$P�un� b 1✓R �L L License Number. '�-n��L�:' L�7/ �� <br />Business Mailing Address: <br />Phone:�� � ��"�— Ol2�j <br />Labor <br />Other Costs <br />CCN Inspection <br />BWV Install <br />Pipe replacement <br />SuAace restoration <br />Site cleanup <br />Downspouts ! drainage imp. <br />Backwater valve <br />Grinder pump _ <br />Side sewer pipe (up to 8 feet) <br />ImpoAed Backfill <br />Surface Restoration Materials <br />��op soil gress seed, concrele, elc.) <br />Cover (irrigation box or load bearing <br />cover) <br />Specity equip nt <br />-�F�t�' �--�M11-� - <br />Disposal fees by item � <br />,�r <br />Deliverv fees it not covered bv lahot <br />Cosls not associaled wilh BWD, anA <br />not elioible for rebale (detaii below) <br />Revised 9/03/2014 <br />Hours <br />Hours <br />Feet <br />Yards <br />City <br />� <br />Gl�+'� <br />3y-7 0 <br />$ <br />