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BACKWATEF� PREVEI�I�'iON PROGFdAM <br />�' INVOICE rO�T BREAKDOWN <br />Please use this invoice Cost Brea„do�vn as a templale for invoices submi:ted as part of the Backwater <br />Prevention Device rebate program. Either this form cr your own im�oic? form with ihe following line items can <br />be submitted. This allows you to invoice your client according to your exisling billing template while allo�ving <br />city siaff to identify how costs elic�ible for the Backvlaler Prevention Device Rebete were accrued. <br />Onlylabor and maferlals direcffy related to the installation and function of a backwater prevention <br />device are eligible for City rebate and therefore shou(d be included on the upper half of thls form. <br />Additiona! costs may bo added to bottom of the form. <br />5�'e:u'f-, �'�"L V <br />Business Name: � G ��e License Number. CrJs.�6 c, <br />��ll�l'�l-ftzL"1-��1C_— - ^ - <br />Business Mailing Address: �(�{-(o l_G[�]c t�� � � «- • � Li�%� �"•! �- ' ""' "- <br />City State Zip <br />Phone:�y(.,� �Gl�_ �•�;�Yl��. Email:�' i {�)i�!'�rnn4� 'c� _'u�----rIP,Sr,:�2�(: C'ciYi� <br />Revised 9/03/2014 <br />