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B�4CKWA�ER PREVEfVTION PROGRAM <br /> � INVOICE COST BREAlCDOWN <br /> Piease use this Invoice Cost Breakdovm as a template for �nvoices si�bmitted as part o`the Backwater <br /> Prevention Device rebate program. Either Ihis form nr your ovdn invoice form e+ith the following line items can <br /> be submitted. This allo�vs you to invoice your client according to your existino billing lemplate�vhile allowina <br /> aty staff io idenlify hoe�cosls e!igible ror the Back�aater Prevention Device Rebate cuere accrued. <br /> Only labor and materials directly related to the installation and function of a backwater prevention <br /> device are eligible for Ciry rebate and therefore sfiould be included on the upper half of[his form. <br /> Additional custs may br� added to bottom of the (orm. <br /> `JrFu::.L�-t- , <br /> 5usiness Name:�;Ti��czL'L <, ' � ,j'[�� License Number: _�r7���______ <br /> C3iisiness fuiailinc� Address: a�i��c LG�C�� �,J��-� �=U��-�� —��`f-`��,'� <br /> City State Zip <br /> r hone:�an��'c`..v�.,S�, _ EmaiI:�J1Y�>�1"C[�taCl�> �i�f1C���.d�4rc�Nf--�'��9 <br /> ' Categor� Descnption ____ � Unifs �uantity Rate Total —� <br /> Administration iidministration/ management Hours _ __ __ ____ <br /> � Labor�CCTV Inspection� Hours _ ��_ �,��-.__._i <br /> ' BbbV Inslall Nours _ __ <br /> I Pipe replar,eme�t Hours — - � <br /> SuAace restoration Hours � l�� �_� <br /> �� Sitecleanup Hou�s -.--- - ---_-------_, <br /> � - - Hours <br /> Do�vnspouls I drainac�e imp. _— _ . - - <br /> Per Unit L C� <br /> � tJlaterials BackwalecvAlve _��-�jUSlltn�. Lh�-1�-14-��---i <br /> f- _ Grinder pump � ----- Per Unil . j T. <br /> � Slde ser�er pipe(up to 8 feet) �ee� ��� L��(_�:�.�_ _�_--�.Z - <br /> � � Imported Back511 Yards ___ ___ . __ _ _--_ <br /> -�--- <br /> ' SuAace Restoration ti7aterials Lump <br /> - �!o soil, rass seed,concrele,elc. sum �LZ__ c�Q___ _ <br /> -e- --�—------- -: -- -- -1---- <br /> � Cover(irrigation box or Inad beanng Per Unil- � � � <br /> cover) ___ - �� <br /> -- -- <br /> -- <br /> -- --- - Hour I <br /> �.Rcntals Specify equipment _--_ _ .-__.-- - . ___ —.- _-�t <br /> -- -I��n:� ��r�1�» _ - -- --� --- ��- --�3�- � <br /> ( Fees- -- Disposal(ci•�s by Itein _. _ _ _ Y�rds . _._ -_ � � .-____—_. __ ^�^��" � ll <br /> ____ . .__-_._ -- - � O� P 1 <br /> ` ' <br /> __ _ __ . ' _-_ _ ._ -_. ._ _ .__ _._.__ . . _ . ._ __ -.� <br /> �'__-_ .- _ _- _—_ _ - _ _ <br /> DeOvery(cr.s d not coverod by ibor , _ _ __ _ _ __ � <br /> _ __ <br /> _ - __ _.__ _. _. . . _.-- ' i <br /> '. _.._ - . ____ _ <br /> _. _ _ . .-_'�- <br /> _- _._ . . .—_ __ . _. � <br /> , Eliqible Total � � � � � , <br /> Othcr Costs �0S1s not associaled�r.ith E3WD, and � <br /> i <br /> i not eh� ible for rebate{delad hefow) -. _ __ <br /> _- - - - - - <br /> - __ <br /> -- --- - <br /> -- — - <br /> - - <br /> �� -Fo i�a COvttro- Y _._ ' <br /> - - - <br /> _ - ----- - <br /> , _ --- -- — - - - . - -�_ v��_U__343�-- -- --- <br /> ; - - -- -- <br /> ---- -- -- <br /> -- - --- - <br /> _-� � - - - -- <br /> ------- -- S <br /> _ _ _ _ __ � K�C. <br /> Ineligible Total ` <br /> rota�- _ - '� - 1 I / qj ( � �• I <br /> �p,�� k,I;i,bdir- — <br /> ' ��s <br /> P,c:'ised 9!0"'�Gf�f <br /> . , <br />