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� BACKWATER PF�EVENTION PROGf�AM <br />� iNVOICE CQS�' BREAKDOWN <br />Please use this Invoice Cost E3reakdown as a template for invoices submitted as part of the Backvaater <br />Prevention De•aice rebate program Either this form or your ovdn invoice form vrith ihe follo�:�iny line items can <br />be submitted. This allows you lo invoice your client according to youi existing billing template elhile alio�ving <br />cily staH to identif� how costs eligible for the Backe•�ater Prevention D.vice Reba'.e were accrued <br />Only labor ana mafer'ials directly related fo fhe installation and function of a backwater prevention <br />device aie eli�ible !or Ciry r�bate and there(ore should be inc!uded on [he upper hal/ ef this form. <br />Addifional cosfs may be addeo fo bottom of th.e (oirri. <br />Businass Name.l-1�71,�I-7 Cczl�-z�,,n,',<<�`�1L��'S� ce se N�er _�S�j�J �___ -- <br />'-t`'"�_' <br />Business �J�ailing Address: o�{(�c-�c L.C�rl�l�_ �� �:—._� '� � -!��L�`�S='-3___ <br />City State Zip <br />Phone:��'�l��_i��� Email:�'-� ��=f�-�t��' G 3l�ii_S.�CI�Sc'�: ' - �'��� <br />-�nrts Quantit Rate �otal _ <br />� ---�—Tnnccriotion ��--- <br />i Catey^^ <br />�� ll�flll( <br />; Labor <br />�-- -- <br />Rentals <br />Fees <br />Eligible Tolal <br />Othcr Cosls <br />Incligibie Total <br />Total <br />iistration I ma <br />Inspeclion <br />Install <br />eplacement <br />:e resloralion <br />DoLvnspouts ! drainage imp. <br />Back�•�aler valve _ <br />Gnnderpum{. <br />Side sewer pipe (up to 8 feet) _ <br />Imported Backfill _ <br />Surtace Restoration �aterials <br />lo _soil, grass seed_concrete, etc <br />Cover (irrigation box or load bcarii <br />very fees if nol covereA hy labor <br />Cosls n�t associaled w.ith �NJD, and <br />not eliyible for rebatr, delail bclo�•�) _ <br />.Revised 9/03/2014 <br />�'10UfS <br />Haurs <br />�— -` <br />Hours <br />Nauts <br />Haurs <br />Haurs <br />Hours <br />Pcr Unit J��S�:� - <br />Pcr Unit <br />Feei /�.�H-� � <br />-t-' - <br />Yards <br />�ump <br />sum <br />Per Unit <br />Hour <br />Yards <br />=-1----- <br />-c�c�,��.. <br />---1 --�_ � �r <br />