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� BACKWATER PREV�NTI0�1 PRU��iAM <br />INVOICE Ct?�T BREAKDO�h'N <br />Please use this Ir ✓oice Cost Breakdown as a tempiate for invoices submitted as part o( lhe Backwater <br />Prevention Device rebate program. Either this fortn or y�ur own invoice form with the following line items can <br />be submitted. This allows you to invoice your client according to your existing billing lemplate while allowing <br />city staff to identify how costs eligibie for the Backwater Prevention Device Rebate were accrued <br />Only la6or and mnterials directly related to the lnsfallation and function o/a backwater prev2ntion <br />device are eligible for City rebate and therefore should be inc/uded on the upper half o/ this lorm. <br />Addifional rosts may be added to bottom ol the form. <br />Business Name: ��C License Number �'7 �'U19� (�I�YQ <br />Business i 4ailing Address: �� (�l,S7Zti�i'-f'l�l 11 f�G �% '^-r / ���� <br />Phone. `--/ � �— ���%—��z�mail:_�_���r'i't�i/'b�(fv�–��1�/1P/�'l � <br />Administration Adm'nistralion <br />Labor CCN Inspecti <br />BVN/ Instali <br />MaMriels <br />Fecs <br />Eligible Total <br />Othor Costc <br />Ineliglblc Total <br />ToNI <br />Surface restoration <br />Site cleanup <br />Downspoufs / drainage imp. <br />Backwater va� ae <br />Gnnder pump <br />Side sewer pipe (up to 8 feet) <br />Imported Backfill <br />Surface Restoration Materials <br />(top soil, grass seed, concrete, etc. <br />Cover (irtiga6on box or load 6eanng <br />cov�- ------ <br />Speciry equipment <br />Dis osal fees by item <br />.�— -- - <br />Delivery fees i( not covered by labor <br />Costs not associaled with BVYD, and <br />not eli ible fir re6ate (delail below) <br />Revised 9/03/2014 <br />Units <br />Hours <br />Hours <br />Hours <br />Hours <br />Yards �U <br />Lump � <br />sum � Z <br />Per Unit ( � � <br />Hour <br />S <br />s <br />0 <br />