Laserfiche WebLink
BACKNATER PRE�O�N�'l6� PROGRAM <br /> rNVOI�CE COST BRE/�KDQWN <br /> Please use this Invoir.e Ces( �reakdo�•m as a template for invoices submitted as part of the Backwa(=.r <br /> Prevention Device rebate program. Eiiher this iorm or your ovm invoice torm with the tollowing line ilems can <br /> ne submitted. This allotivs you to invoice your clien!according to your existing biiling template�vhile allo�:�ing <br /> city staff to identify ho�v cosis eliyibl^ for the Bachwater Prevenlion Device Rebate v;r.re 2ccrued. <br /> Only labor and rnaferials directly related to the installation and function of a backwater prevention <br /> devlce are eligible for City rebate and therefore should be included on the upper lialf o(this form. <br /> Additional costs may 6e added to botforn of tho (orm. <br /> I /� 1 (� <br /> cR:�, ��ti �=3��� License Number. I � '-'`"�`� v � <br /> 6usiness Name:�S�,��`l� _ �-- <br /> -� > l �f� <br /> B�.isiness Mailing Address _�,> �7�' � � -�'U �G ��'G"tr _�_ ���`Z�- <br /> I City, Sta(e� Zip <br /> Phone.�'t'J�-y65 '�llq3 EmaiC t�sc�,.�c�����r�,��i.�.���,n _ � ��1ur� ��M — <br /> �Cate o �escn tion Units Quantity Rate Totai - _ _ <br /> �Admin�istrati"on Admimstration/management Hours _ _ _ i <br /> 1---- — —.- <br /> � Labor � CCN Inspection Hours __ _ ___ <br /> BWVlnstall Hours � � <br /> i ^ Pipe replacement Hours <br /> Sudace restoration Hours�_ ��Q,f.b _ _� ,DO <br /> � Site cteanup Hours� � _ _ _ <br /> Do�vnspouts/drainaye imp. Hour ' i <br /> �9aterials _�Backweiervalve PerUnil'_ � �OCJ,O� ,�_r,���OO <br /> ' Grinder pump Per Unil I <br /> Side sewer pipe(up lo B feeq Feet � _ _ <br /> imported E�ackfill Yards__ _ <br /> Surface Restoration Rlaterials Lump <br /> lo soit. 3ss seed, cancreta,elc sum __.__ _ �.- <br /> Cpvo + ation bo or load bearing rer Unit � aU��� �0 �� <br /> cove - -- — -- - <br /> Rentals Specify equipment Hour _ _ _ _ _ <br /> - -- -- - ----— -- -- - - —I r� <br /> Fees Disposal fees bY ilem_ Yards , a.5 __ a(�.�D_ _�O�' � <br /> ---- ---_. �.._---_----- T� <br /> Delivcry lees if nol covered bs iabor �_S-��p � �a�,O0 _ <br /> , <br /> - - - --- - - - _ ' ' - <br /> --- --- �(f��!��L. �105 /i <br /> — --_. - - - - ---- <br /> Eli ible?otal T'tr ;� " 5,16 S. <br /> Other Costs Costs not assuc:aled�vith BW�,a��d I <br /> noleliyibleforrebate(detailoelow __ _ _ ___. _ ` L�<<_-���-_�!'�''�1 Cn�ll2ztl-c�� <br /> - - --—'- -— - - __ - -1.--��a'��=i�t' �13 Q J 3 <br /> ---- ���u� - <br /> — - � �,t�(�• l <br /> - -- — 7� <br /> ----- — - ---- -'Y—G (S <br /> __ _ - - <br /> Ineligiblc Total � <br /> Total _- S <br /> � ----1- - <br /> Revised 9/0:1/2014 <br />