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; <br /> � <br /> ���������� ���������� �������� � <br /> � �N071��p6o� �r�v��r �5'E�6�G�l.F�b9JVfY 1� � <br /> i <br /> r <br /> Please use this Invoice Cost Breakdov�n as a templale 4or invoices submitted as part o!the Bacicwater i <br /> Prevention Device re6ate program. Either this form or your own invoice tor'rn vrAh the tollowing line items can <br /> be submitted. 7fiis allovrs you to invoice your clienl according to your existing billing template while allowing <br /> city stafl to identify how, costs eligible for ihe BacMraater PrevenGon Device Rebate were accrued. i <br /> � <br /> flnfy I,:bar and ma�erials diresHy relafec6 to tir�insPallatEan an�Sune£iarr o1 m�clnvaPEr peeverua� � <br /> device are eligi6le Par C'rfy re�stife and fherePore siro€�/�ba incl�rde�on eha upper AaFP o9 Uds i�m:. <br /> Addifional costs may be added Po boffom o;the form. <br /> Bus�ness Name: �',���Q/e�'C7�f b���— L.�License hlumher: ��ti�'�t�' ��"� ' -��— � <br /> Business Mailino riddress:__�_�,�_t,�!d`�" �-���- ����� ��v� � <br /> C1 St e , Zip . <br /> Phone: ��'�� — '��o!—C�LZ�J Email:�_���tsv'� �^�t� e.�`�/� �'i'71�� � <br /> Catectn�_ Descri ian Uni4s Quan9� Raia Total <br /> ftdminis4ra4io� Administration/managomeN Hours � <br /> ��T CCN Inspection Hours / t�� � <br /> BWV InsL�ll -- �-- � Hours / --,�C� � <br /> Pipe replacement Hours <br /> Surface resloralion Hours � ' <br /> Site deanup Hours f <br /> Downspouts!drainage imp. Hours -- <br /> Niaterials Bacicwaler valve Per Unil _ "Z5� <br /> Gnndcr pump Per Unil _ _ <br /> Side sewer pipc(up to 8 fcet) Feel � <br /> Imported Back�ll Yards <br /> � SuAace Resloration Matarials Lump / >�� — ' <br /> f�" � to soil, nss seed,concrele,elc. sum �� <br /> Cover(irrigation 6ox or load bearing Per Unit ; <br /> covcr� — - • <br /> Rentals Specify equipmenl __ Hour _ <br /> Fees � �Isposal fces by ilem Yartf:; .—_ <br /> 'V�U — -- <br /> ��— --------. -- -- -- --- <br /> Delivery fecs d not coverad by labw ,.�— <br /> ----- -- ----- $-��� <br /> EG ible To4ul w . _ -- ; <br /> Othcr Costs Costs not associated vr.11i 9WD,and �v <br /> _ _ not eliyible Tor rebate dcl8il betow _____ _� � - — ��� . <br /> --- --- --- - - � -��`- . <br /> - ---- -- - _ 3� <br /> --- $ " � '. <br /> Ineli�ibleYotal . .a�..��-� � <br /> To9a1 —_ --- — $ ----- � <br /> Revised 9/03/2094 <br /> � <br />