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BACKWATER PREVENTI�N PROGRAM <br />°�F 1NVOICE COST BREAKD(�WN <br />Piease use tllis Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your own invoicc Form with the follovding lino items can <br />be ;ubmiited. This ailcws you to invoice your dient acc�rding to your existing billiny template while allowing <br />city siaif to identiiy hbvd cosls �ligible for lhe Backwater Prevenlion Cevice Rebate vuere accrued. <br />Onty labor and materials dlrectly related to the installation ;,nd function of a backv�ater preveniion <br />device are eligible for City rebate and therefore should be i�cluded on the upper half of this form. <br />fidditionai cosfs may be odded to bottor�� of the (�rm. (�I -�7� <br />Business PJane: ��c�e 710� �'�l a"��SB`��� _ License Numbe�r. f�l/SC�� SS �' ',-+- �� <br />k3usiness Mailing Address: ���_ .���� •�+% . C�h�'1v�(�S Idll�— ���6 <br />n City Sta(e / Zip <br />Phone: 7.L� �_ "—Il'f�� — Email: /'��S,�u��.,, c �� ���•-�) ��yy`J (�cv';�— <br />Administration � Adminisiration I <br />Labor CCTV Inspect�o <br />�WV Install <br />tJlatarials <br />Rentals <br />Fces � <br />Elir�iblc Total <br />Othcr Cosls <br />Su rf. �ce <br />Site de: <br />Backwater valve <br />Grinder pump <br />Side sewer pipe Sup to 8 fcet)_ <br />Imported �eckfill _ _ <br />Surfacc Restoration Matr_rials <br />�to_� il, grass seed, wncrete, elc <br />Crnrcr � ngalinn 6oy.Vr load bearir <br />c�ver lf " <br />8pacify eyuipment _� , <br />Hours <br />Hours <br />Hours <br />Per Unil <br />Feet <br />Yards <br />Lun �p <br />�Isposal lees by ilem ___ Yards <br />[7elivery fees i( nol covered by labor <br />Costs not assor,i�ted wdh BWU, aod <br />not ��liqible fnr robate (detail below) <br />1 � ---� d �u,�c� _. ;�, r:�r� <br />--- - .S�,G _ �.��o.��d._ <br />_ — — _ — — <br />_ _ _ _--_I A1C �-- =---�D �. //�� , <br />— — - ----� <br />Incligiblo lota�--_ __ .— <br />Tatal � _ <br />f�'evi.s�ed '�/03/201 �7 <br />' { ocl�u_r_ �- -P^ `o.p�„ <br />i..J _ . <br />7'1��,_<._.r __ <br />,i4� �c.'..��,�, <br />__�fi -- <br />(' � cY l�l il� <br />� y _—__. <br />