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BACKWATER PREVENTION PROGRAM <br />04 T INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breukdown as a template for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your own invoice form with the following line items can <br />be submitted. This allows you to invoice your client according to your existing billing template while allowing <br />city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only labor and materials directly related to the installation and function of a backwater o(this form <br />device are eligible for City rebate and therefore should be included on the upper <br />Additional costs may be added to bottom of the form. <br />9 raid License N�er'. 5 <br />Business Name;r�IPr-i rr n ��_, e---�- -- <br />Business Mailing Address: vA&X W LZ rlc LI v w r- — <br />City State Zip <br />Email: <br />Phone: z -�Ir�m Clc me _n! Grtnf( 5:�1iPrri"r CxiY3l <br />s <br />Cate o <br />ascription <br />Unfits <br />Quanti <br />Rate <br />Total <br />Administration <br />Administration / management <br />Hours <br />Labor <br />CCTV Inspection <br />Hours <br />BWV Install <br />Hours <br />pipe replacement <br />restoration <br />Site cleanupDownspouts <br />PHSurface <br />I drainage imp. <br />Materials <br />Backwater valve <br />Grinder pump <br />Side sewer pipe up to B feet <br />Feet <br />r r <br />Imported Backfill <br />Yards <br />surface Restoration Materials <br />Lump <br />d <br />to soil, rass seed concrete. etc. <br />sum <br />Cover (lirigatton box or load bearing <br />Per Unit <br />! <br />cover <br />Rentals <br />Specify equipment <br />Hour <br />Fees <br />Disposal fees by item <br />Yards <br />Delivery fees if not covered b labor <br />Eli ible Total <br />Costs not associated with BWD, and <br />Other Costs <br />not eligible ible for rebate detail below <br />a. <br />r <br />5 °Ilr�hs <br />Ineligible Total <br />$ a <br />Total <br />— <br />'t'JtS <br />Revised 9/03/2094 <br />