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f <br /> i <br /> �A�9��9���� �'�����T��� P�$��RAN! <br /> � �NV�I�� �0��' ���AlCDC��/N ; <br /> Please use this Invoice Cos' Breakdown as a template for invoices subinitted as part of the Ba��kwater <br /> � <br /> �revention Device rebate program. Either ihis form or your own invoice form with the following il�e ilems can � <br /> be submiried. This aliows you to invoice your client according to your existing billing template while allowing <br /> city staff to identify how costs eligibla for the Backwater Prevention Device Rebate were accrued. <br /> 6nly labor an�materials dire:;tty vefafed to Ehe instalfatian and Surtction of a backwaPer pr�vention i <br /> device are eligi8le 7or Cit;�re�aPe and cherefcre shouid be incPuded on fhe upper hal�of 4his form. <br /> Addilronal costs may be added to bollom o(the (orm. � <br /> Business Name:��� � �� n`��Licensa Number. �p��"D''b(/Fn ' <br /> Business Mailing Address' � f� � � ��'�� �"a---��� ��Z U� � <br /> Gry State Zip i <br /> � <br /> Phone �� ) L� g 9—QJ Z ��Email: � <br /> Cute o Desce6 !i�n (lnits Quantit Rate Total j <br /> i <br /> Adminishaiion Administration I management Hou�s i <br /> Lnbor CCN Inspection Hours �3�� ; <br /> BVW Install Hours �2- � <br /> Pipe reptacement Hours i `L� ; <br /> Surface restoration Hours Y � � <br /> Site cleanup HO°� ` �� r <br /> Downspouts I drainage im . Hours � <br /> Per Unit � Z � <br /> 11Natcrials Backwater valve per Unit <br /> Grinder pump <br /> Side sewer pipe (up l0 8 feelj Feet � <br /> Imported Backfill Yards — <br /> SuAace Restoralion Materials Lump + 2'7 SJ <br /> _(toP soi1, Srass seed,cancrele, etc. sum � <br /> Cover(irrigation box o�load bearing Per Unit �S� <br /> cover_ <br /> en4als Speciy equipment Hour ___ <br /> - �� i _� —a��- -- <br /> Fecs Disposal fees by item _ Yards ____ <br /> Delivery fees if not covered by lahor _.__ -- <br /> ..---- �� — ---- -C-�---j� -- <br /> - -- L) $� <br /> _EI, i��blo Total ,�,,.,,,,... �•` <br /> Costs not associaled with BWD, and <br /> O¢hcr Casts not eligihle tot rebale�detail below_ _ ___ ._— -- ----�- <br /> --- --- �' -- $ G-�J-��.__" <br /> �.-- ' . <br /> Inel^��gible Tot�l .�_ ��� -�^�^ ""� �.7 7� Y� <br /> �.. <br /> Total -- -- -- -- __ _—. ----- — _-- ----- - -- <br /> Rnvised 9/03/2014 <br />