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BACF�CilllATi �� Pi��O/Ef��i i(�I� F'ROGRAtiA <br />E� INVOICE COST BREAKDOlIVN <br />Please use this Invoice Cest 8reakc�o�:�n as a template for invoices submifted as part of the Backwater <br />Prevention Device re6ate program. Either th�s form or your own invoice form with the follo�ding line iterns can <br />be submitted. This allows yc,i io invo�ce your client according to your existing billing template while allowiny <br />cily staff to idenfify how costs eligible ior the 6ackwater Prevention Device Rebate v��re accrued. <br />Only labor ar.i materials directly related to the installation and fanction o(a backwaterprevention <br />dev,"ce are eligiblc for City rebate and therefore should be incfuded on the upper half of fhis form. <br />Additional costs may be added ro Lottom of the form. <br />/ H <br />Susiness Name:��foL�+�W1� S�"-'�cense Number. _ o S � <br />Eiusiness A4ailing Address: ���� � a 4 S� S� ��"�1�N �i� I��a �j _ <br />/ n City State Zip <br />Phone � ���/.S'��q� EmailY�� eS�<«I a�1�Se�_Q_Cfllu<<' , �cic <br />�-- <br />Administretion <br />L.abor <br />Rentals <br />Fces __ <br />othcr roscs <br />CCTV Insp[ <br />aWV Install <br />Suriace restoration <br />Downspoutsldrainage <br />Backwalervalve <br />Grinder pump <br />Side �ewer pipe (up to <br />Imcorted Backfll <br />Surtace R�storation Malerials <br />(l� soil, qrass seed concrele, etcJ <br />Cover (irrication box or load bearing <br />Hours <br />Hours <br />Hours <br />Hours <br />Per Unit � <br />F2et <br />Hour <br />Oisposal fees by item _ Yards—� <br />Delivery fees if not covered by labor- --- I <br />I <br />I <br />Cosls nol assor,ialed with CiVJD, and <br />nol eligihle'or rebote (detail hr.lov+j_ _ _ _ <br />— ---�- <br />� <br />i� --- <br />� Ineiigibie Total � <br />I Total — � <br />Revised 9/03/2014 <br />0 <br />� q�'-- <br />Total <br />�--°c' - - --- <br />S �.6 ;-- a0S0. �_ <br />Ti�x;. __ 18�3,bc7 <br />$ <br />$ <br />T�y � <br />Cos•�— <br />