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i <br /> BAGKWATER PREVENTiQN ���iOGRANf ; <br /> INV�ICE COST k3REA9CD�OWN ; <br /> Please use this Invoice Cosi 8reakdown as a tempfate for invoices submitled as p;aA of Lhe Ba�kwater � <br /> Prevention Device rebate progrem. Either this fortn or your own invoice form with tne followiny line items can <br /> be submiHed. This allows you to invoice your client according to your existing billing template while allowing �. <br /> city staff to iden�ify how cos!s eligible for fhe Backwater Prevenlion device Rebate were accrued. I <br /> Only labor and materfals directly related to the installation an�lunction af n backwa��r prevenfion ! <br /> device are elfgible for City rebate and there/ore should be included on the up�r hatl of thls form. <br /> Additional cos(s may be added!o bc trom o(the lorm. <br /> Business Nams: - u✓1� 1 7�(' ' License Number.�� Q� ��� ' <br /> � <br /> Business Mailing Address: �„�'�"��� V/S'�Y�=-l��- ,��- ��r--���� �g��r� ' <br /> // Ci�Y State Zip . <br /> Phone: �-�- `If3�—U/Z� Email: �r,2��/� � �, ,7 - r� . C.U'^"` <br /> � <br /> Cat o Description UniW Quu " Ratc 7otnl ' <br /> Administration Administration/managemenl Hours ; <br /> Lahor CCNlnspection Hours Cy � <br /> BNN Insfall Hours Z � <br /> Pipe replacement Hours , <br /> Surface restoration Hours <br /> Site cleanu Hours `Z7 � <br /> Downspoutsldrainageimp. Hours � <br /> Materialc Backwater valve Per Unit � 'Z � � <br /> Grinder pump � Per Unit � <br /> Side sewer pipe(up to 8 teel) Feet <br /> Imported Backfill Yards ! <br /> _ � <br /> Suriace Restoratlon Matenals Lump j <br /> to soil rassseed conctetr. e1c. sum � � S � <br /> Cover(irrigation box or load bearing Pcr Unit � <br /> cover) _ j � � i <br /> Rentais Specify equipment Hour <br /> Fee^ Disposal fees by item YarUs <br /> ��. __ _— —_ —� `-r� i <br /> Delivery fees il not cuvered by labor _ _ _. <br /> Eli iblc Totnl --- --- ----� —. —' -- -- $ -��' � ,� <br /> Other Costs Costs not associated with BWD,and � � �� � �- � <br /> not eli ible for rebate deWil bclow <br /> — --- -- — i <br /> -- ; <br /> -----_- - �q,� - �j <br /> Ineflgible Totnl �'' ` g ' <br /> Totnl � <br /> �---- — . <br /> Revisnd 9/03/2014 � <br />