Laserfiche WebLink
i <br /> BACKWA�ER PREVEiVTIt�f� Pe3�OGRA+M <br /> E� � INVOI�IE COS�' BREAKDOWtV <br /> Ylease use ;his Invoice Cosl Breakdo�^m as a lemplate for invoices submifled as part of thu Backv.�ater <br /> Prevention Gevice rebate program. Either this fom. or your ovan invoice forr� vdith the follo�ving line items can <br /> be submilted. This alloNs you lo invoice your client according to your existing billing femplate while allowing <br /> city staf(lo identify ho�v costs eligible for tne Backv�ater Prevention Device Rebate were accrued. <br /> Only labor and materials direcGy related to tne ins�al/allon and function of a backv�aterprevention <br /> device are eligible for Ciry rebate and therefore shoufd be included on the upper half of tl�is forrn. <br /> /�ddiiional costs may be added(o bottora of the (onn. <br /> ���,. �— l,[.C� <br /> J,.�ci.. , /,c� <br /> [�, License Number. _(�j��JJ�1__ ___ <br /> Business Name:f�y�'1Pri��.1� ��+"�.�1:,�� - <br /> sLrn.���. I� �� .�%� _t,�l� U�� �.�c :� <br /> f3usiness IJailing Address: ��i%�c L-Ge � ' State Zi� <br /> City <br /> Phone:;�.(o'�G_�'��� _- EmaiL_ • c�iltiCt�cr���i�.s�ki_�ldr��„' . C��--��� <br /> Catcyory Ocscription Units Quantit Rate Total _ � <br /> 4 Administration AdministraJon/management Hours - - <br /> Labor GC7V Inspection _ Hours __ _ �� _ <br /> BVJV Install Hours _ __ I <br /> f- — _ <br /> Pipe rep'acement Hours -�� <br /> Hours �_V---�~ � <br /> �--- Surtace restoration_ _ � _ — --- <br /> Sito cleanup Hours <br /> � Dov:nspouls I drainage imp. Hours <br /> Materials Dackwaler vaive _ _ Per Unit ' _____ _ - <br /> i Grinderpump PerUnil <br /> � Side se���er pipe(up to 8 leet) Feel�"�a"__iI��•�7_Fj� ____�_7--- <br /> Impurted Backfll Y���s I __1 _-- - I <br /> I - Surfar.e Reslnration Niatenals Lump <br /> i�--- <br /> � �o soil, grass seed, concrete,etc.L_ sum _ _ _ _�C 7 --�� - J <br /> I Cover(irrigalion b�x nr load bearing Per Unil I �� I a <br /> r.over _ _ _ -1-- I <br /> i Rentais SPP�ify equipment __ HOut i_� � —_- _ ---- -- —J <br /> ; _ --_--__ �L�tLi.__'�1lLt�-- ___L___�-.X7a--�J�- <br /> Fees __ _ ___. OisPosal fr.es 6y ilem . _ Vards __'___ -___ ____ '3�_by � I <br /> I' _ -. _-___ '� _- _. - — ___._ -_ __-- __ _ _-_— _� <br /> � J Dclivery fees if nol r.overed Uy labor _ __ _ _ _ _ - — -- <br /> . - - -- t-�--- - � --- " - <br /> , I -- - --- — -�- � <br /> Elioibte Tolal � - --- -�---�-- -�-- - -- - <br /> Costs nct associaled v:ilh BWU, ond <br /> Othcr Costs not eligib'c for_rsbate delail bPlo�v -- <br /> - - - - - - <br /> -- — ----_0�' la .� cwstvas LTi� <br /> - - <br /> ---- -- —— - <br /> F-- _ -_ _ 3,�. -�.a�a- t�4�3 <br /> � — _ <br /> ' --- _ _;_'?tinyb "r`t__ _ _ _ <br /> --- --- — -- I- ��_ !��1ti.rc — <br /> I ineligihle Total - -- - --- I 1 I <br /> , Total .. ��. _ ' _ J._�' �:'�:5 QL��� <br /> R�viscd 9iO3i°014 <br />