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BACKWATER PREVEIVTION PROGftAI�JI <br />INVOfCE COST BREAKDOWN <br />Please use this Im�oice Cost Breakdcwn as a template for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your ovm invoice form with the following line items can <br />be suCmitted. This allows �ou to invoic� your client according lo your existing biiling template while alloiving <br />city staff to idenhfy how cos;s eligible for the Backv�ater Prevention Device Rebaie were accrued <br />On:� faborand materials directfy irlated to the instaUafion and function ofa backwater prevenNon <br />device are eligi6le foi City rebate and tl�erefore should be rncluded on the upper half of this form. <br />Additional costs may be added fo bottom o( the form. <br />�F-ctii'+ , LLl� /,.v <br />Business Name:�yg'l�q�-i� � �. .•`a�L� Llcense Number. _�S_,�r",1.-L�______ <br />��.. <br />E3usiness Mailing Address: r��c% LC"���i��--._� '� ' —�-{�A G G���3— <br />City State Zip <br />Phone:�,-�/(�--�,�i'�--EmaiC n, JCCt�c3n�� ` lL]�1.5;d�5r�'�=-���?77� <br />�Catc ory �oscription __ Units Quanti Rate Total __ _ <br />Admmistration I Adminislration / management ' Hows <br />LI abor-----� CCTV' ��sPeclion-- _— Hours —1 ---- - <br />Eli ible T�lal <br />Othor CosLS <br />Ineliaibie 7otal <br />Surface restoration <br />Site cleanup <br />Downspouts I drain <br />8ackwater vaive <br />sewer pipe (up to 8 feel) <br />rted Backfill <br />,cc Resloralion hlalerials <br />Disposal (ec.^. hy ilr�rn .._ . <br />Dclivery fees if nat cnvcred by labor <br />Gosls nol associated with BWD, and <br />not eligible tor rebate {detail below�__ <br />--� �-Uhl� <br />-v-' <br />Revised 9iO3/2014 <br />