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f�Wc�K����� �RE`�8�I1@TI0�9 �ROt3RAlliO <br /> � 8�1��9�� �0��' ��Ef�KD(?V1�fV <br /> Please use.this lnvoice Cost Breakdown as a temolate for invoicessubmitted as part of the Backv�ater <br /> Prevention Device rebate program. Eilher this form or your own invoice form e�ilh the follo�ving line items can <br /> be submitted. This allo�vs'you to invoice your client according to your existing billing iemplate while allowing <br /> city stafi to identify hov� costs eligibie for the Backv�ater Prevention Device Rebate vaere accrued. � <br /> Only labor and materials directly related to the installation and funcfion of a backwater prevention <br /> devrce are-eligible for Ciry rebaPe and therefore should be included on the upper.half of this fo�m. <br /> Additional cos(s may be added to bottom o(the(orm. �L� <br /> �'r%G�� � ' J��C/ �. <br /> Business Name`.�;�1_,���.��L�_,L 5E'��-��L'— License Number. _�L��,2L�1— ' <br /> Business Mailing Address: o�G:c�c LCt r�c�l K.l t�-• r Ilr'1"�,� !.l�� ��'�c�3 � <br /> City State Zip <br /> Phone:o��`�rr� •-;�'l�-=� EmaiCl.ifY�e>iin���rit�n- � � a�i�i�;,iN,4N�r.�� <br /> Catego � Deseri tion Units Quanti Rate Total <br /> Administration Admini;iration/management Hours � <br /> Labor CCTV Inspeclion Hours '? ?� �. <br /> gWV InStall liou�s <br /> Pipe replacement Hours _ _ <br /> I Surtace restoralion Hou1s <br /> Site cleanup Hours <br /> Downspuuls/drainage imp. Hours <br /> Materials Backwalervalve PerUnit� ��C��i�v,_�,("(�-�-.�� ��_ <br /> Grinder pump PerUnit � <br /> Side sa�ver pipe{up to B.feel __ Feei �� �' �__��' . <br /> Imported t3ackfll Yards <br /> Surface Restoralion Materiais Lump � <br /> Llop SOIIi fg ass SP.Zd concrete,elc.) sum , <br /> i Covr.r(irri�•dion box or load bearing Per Uni! I <br /> cover �l--_ - <br /> L--------� --- Hour <br /> Rentals S ecify equipment <br /> :---�_- _� '�:��� <br /> - -�.�_ <br /> Fces Disposai fcr_:: by item Yards <br /> �a�= <br /> Delivery fees if not covered by labor � __ _ ____ ___--_ <br /> Eli IbleTotal 7 a' � � � <br /> Other Costs Gosls nqt associated�;�ith BWD; and <br /> not eli ible for rebale�etail belov� __ <br /> —--- --- �_ 't�.�r%wl rc 1�r�_c' T✓ _ <br /> - �}.c—� .��- -��----- <br /> ---- -- � . <br /> — � <br /> � -�. - . <br /> i. L , , � i r� �Ir <br /> -�� ' NI .. Z. <br /> Ineligible Total , ,�� � S <br /> Total . . �--- � .. . . . .... -- . ,$ - � . . <br /> Revrsed 9/03/2014 <br /> , _ _ <br />