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BACKiiif�iTEl� PREo0Ei�1 i iOP�! PROC�R�A�iii <br /> INVOICE COST BREAKDOV�JN <br /> Please use [his Invoice Cost f3reakdcc:n as a template for invoices si�bmittcd as part of the Backwatc:r <br /> Prevention Device rebate pro�ram. Either tnis form or your osvn invoice (orm v�itn the �oilowing line iterns can <br /> be :.ubmifted. This aiiows you lo im�aice your client according to your existing billing template��hile allo�ving <br /> city staff to identify ho�.v costs eliyible for the 8acktva!er Prevention Davice Rebate were accrued. <br /> Only labor and materials directly related to ihe installation and function of a backwater prevention <br /> device are eli,qibfe (or City rebate and there(ore shoufd 6e incfuded on fhe upper half of[his form. <br /> Addition�l cosfs may be added to hoffom of the (orm. <br /> Business IJame j7�«����°1d- ��License P'umber: VSU �C{?1��5 _ ____ <br /> A --- �> -r ' /� � <br /> Business Mailing Address:�dJ �����.7f '7�__L�r�a�s _ wA. Qg°2E <br /> �;-� ���� � n fCity Sta� Zip <br /> Phone:g�'f7. "Ir7- __��=13 _Email:�.��Grlt�2.s�,��.� n�,cl ��� I!�GI� tt�J. 40M _ _ <br /> ' Calc�ory __I Description Units � Quantity i Rate Total _ � <br /> � Administration � Administation I management Hours �_ �� <br /> -i <br /> Labor �� CCN Icspection Flours a J <br /> I -------- -1�--- - - <br /> ' 6U�N Irs:all Hours 0 I <br /> Pipereplacemenl Hours �JQ_ �� <br /> Surface resloration I lours ' <br /> Site cleanup Hours � _ j I <br /> � --- -- <br /> �_�_� Dotmspou�s/drainageimp. Hours � <br /> Mati erials j BacMvalervalve _ _ PerUnil �_ �- O-�U <br /> � Grinderpump _ PerUnit _ <br /> Sic'e se�+�cr pipc(up l0 8 reet) Fe�t .w_ __,T <br /> i �orted Backfill Yards _ _ _ <br /> � Suriaca Restoration Malerials �ump � <br /> ��7 soil taSs�-5�e , concret0.etc _ sum <br /> I Cove (irrigation box r load bearing Per Unll j '1�,o� �.� <br /> coverJ--- - �.---- �- — <br /> Rentala --- - ,Specifyequipmenl----. - Hot�.' <br /> r Fees� _ hisposal fees�item _--- Yards \� .O�`� �G.G� - - ��� <br /> � Deliv�•ryl��usdnolcovr,redbylabor� _ '}�.�J%'--- �����.� <br /> , - . -- . � _ .. . . - i -- -- �tk� ' - --���GC� <br /> I Eli{ible Total - - - -- �' •U� <br /> i Other Costs . ' Costs nol associaled wilh RVJD, and �- - .. . - -- -- <br /> not eli9ibie lor reb�le(detail I�elow) , <br /> I - - �- — .. . - --- - -- <br /> _.�_ ---- - - �LOh,- _ : <br /> . - _ �a h! �l-or { <br /> � ____- ---- - -- - �� ---�)-7�t�- -- - - - <br /> � ` ptt�C. C I <br /> ' _ —__—___�____ __ '.1."`._._ _ _ � <br /> � IneliglbleTotal � � Il Y g . '+����ll <br /> Total_ _ � -- - - �— - � --- - - -- }-" "�``,fIS i <br /> Revised 9'117�?Ol�l <br />