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BACKV':ATER PREVENTION PROGRAiVI <br />� INVOI�E COST BREAKDOWN <br />Please usP `.his �nvoice Cost Breakdown as a template for invoices submitted as part oi th� Backvrater <br />, Prevention Device retate program. Either this tortn or your own invoice form with the follo�ving line items can <br />be submiried. This allo�'s you to �nvoice your clienl according to your existing billing template vdhile allowing <br />city staE( to identify how cosis el;gible for the Back�vater Prevention �evice Rebate were accrued. <br />Only labor and materials directly related to the instal!ation and funciion of � backtvater prevention <br />device are eligible for Ci .ry rebate and therelore should be included on the upper half of this (orm. <br />Additional costs may bo added to bottom of the form. � <br />/}��,,,���� 5'e�ti C-, �"'` ' � �'-�� <br />Business Name;AmP��t"�.--s—'� License Mumbec _ ��; � ^ — <br />Business Mailing Address: �il�uc (-Gt rl�b'l tl� �--• __J�L'�a � w� �."� � �':>" `�' <br />Cily State Zip <br />Phone:�(�,•�l��_'�`�� Email: r�> �y},��l�an�,����r��i 5' �i�� �rs,�°(:C's�7 <br />Labor <br />Materials <br />Rentals <br />Fees <br />Eligible Total <br />Ochcr Costs <br />Total <br />Totsl <br />Adminisiration / rnanagement <br />CCTV Inspection <br />gUtN Instail <br />Pipe replacement � <br />Sudace resloration <br />Site cleanup <br />Dovmspouls / drainage Imp. <br />Oackwater vaive <br />Grinder pump <br />Side sewer pipe (up to B f2et) <br />Imported Backfill _ <br />Surface Restoralion Nleterials <br />�p soii qrass seed, concrete etc.) <br />Cover (irrigalion box or load bearing <br />cover - -- — <br />Spocify equipment _ __ <br />�A �7C�.--���' — : -- <br />Disposal fees by item _ _ _ <br />Delivery lees i( nol covered by labor <br />���r ' � , 'K�� <br />Costs not associated wilh BWU, and <br />not eligible for rebate detail belo�v _ <br />Ravisod 9/03/2014 <br />Hours <br />Haurs <br />Hours <br />Hours <br />Hours <br />Hours <br />Per Unit <br />Yards <br />Pcr <br />Yards <br />� <br />�� <br />li <br />