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I <br /> � <br /> BACKWATER PREVENTION PROGRAM ; <br /> INVOICE COST BREAKDOWN � <br /> Please use lhis Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater ! <br /> Prevention Device rebale program. Eilher this fortn or your own invoice form with the following iinc items can ; <br /> ba submiited. This allows you to invoice your client according to your existing billing lemplate while allowing � <br /> city staft to identify how costs eligible for the Backwater Prevenlion Device Rebate were accrued. i <br /> I <br /> Only labor and materials direcNy related to the installation and furtction o/a backwater prevention � <br /> device are eligible lor City rebate and therelore sho�ld be included on the upper hal/o!this form. � <br /> Additional costs may be added to bottom ol the lorm. ' <br /> Business Name: <br /> jg-� P/U'ryl bf l'j�u.C� License Numher: l��-Q�� ��d� ��� � <br /> Business '�lailingAddress: �__�� v<<^'� a�� I ' vV ���LT ���� j <br /> i C�y Sl e . 2ip . � <br /> Phone: LZ - `i��l-C�1 L�J Email:_�-_�Vm..�(Vl'i LLC `� �� , <br /> Cate�or�_ Descri tion Unils Quantit � Rate Totaf ± <br /> Administralion Administration/managemenl Hours � <br /> Labor �CCNlnspection Hou�s / ' <br /> BWV Install � Hours / __���� __ <br /> Pipe«�placemenl Hours ! <br /> Surlace restoralion Hours � _2��� ' <br /> Sile deanup Hours f � --- + <br /> Downspouls/drainage imp. _ Hnurs 1 <br /> Materials Backwaler valve Per Unil _C_ 7 5� y <br /> G�inder pump Per Unit _ I <br /> � Side sewer pipe (up to 8 feet) Feet i <br /> I-- i <br /> Imported Backfill Yards ! <br /> ��S SurfaceResloralionMalerials Wmp f� ; <br /> to soil, rass seed conerete,elc.)_ sum _I __ _/� ' <br /> i ` Cover(irrigalion 6ox or load beannc� Per Unil � <br /> cover) -- � <br /> Rentals Speci(y equipmenl _ Hour _ � <br /> - --- --- -- <br /> Fces Disposal Ices by item _ Yards <br /> - - -- -- <br /> — -- --- - <br /> ^ �- '7C) <br /> ��� Delivery fces if nat covered�labor <br /> - - ' <br /> . - __ --- <br /> - ---- - <br /> --—_ <br /> . _.- ._- .. _.._-�L- -- -S i <br /> Eli ible Total $ <br /> � <br /> Olhei Casls Cosls not associaled wilh HWD,and � <br /> nol eii ible for rr.ba�e(detall heloe�j - . _—----- � O i <br /> - --- , , <br /> ---.__ ------ -- _ -- - ---- -- - - '��-.-� �Y� <br /> - I <br /> - ---- -- <br /> - - + <br /> ------ - -------- - 3�, ; <br /> ---- - - --- -- --- - ---- � - -� - .� `� <br /> Ineligible Tolal <br /> Total ------- -�- <br /> Revised 9/03/2014 <br />