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BA�KWATER PREVENTIOf� PROGRAM <br /> INVOICE COST BREAKDOWN � <br /> Please use this Invoir.e Cost Ereakdo�.vn as a template for invoices suhmittecf as part of the Backwater <br /> Preventien Device re�ate progrart�,. Either this Torm or your own invofce form wilh lhe tollowing Ilne items can <br /> be submitted. This allows you to invoice your client according to your existing billing template while allowing <br /> city statf to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> Onty labor and materials directly rela:ed to the installation and lunction of a baclnvater prevention { <br /> device are eligiufe lor City e•e6ate and therefore should be included on the uppe�half of thls form. i <br /> Addi(ional cosls may be added to boffom ol fhe lorm. , <br /> Business Name: ��'�UY✓b I�'� L .�- License Number: � �����_ `. <br /> � <br /> Business Mailing Address: tr"� CL L 1 I.��� �F��� ��L<< �� ��'Z�'�'`=� "" � � �`2� �L' � <br /> Cdy State Zip ! <br /> �7 - nl- U � ��� «�`� � <br /> Phone: L ) - �1��__ 12�j_Email: G� �- ri l�ii'Z�i �'1 C ��(� ' (37�a l • L , <br /> �Cate ory Description Units Quanlit _ Rate Total � <br /> dministralion Adminislretion/management Hours _ _�-� � <br /> �abor CCTV Inspeclion Hours �DO <br /> ^ BWVlnstall Hours i , 'S U � <br /> Pipe replacemenl __ Hours � 3 S� <br /> Surface restoration Hours / L/ � . <br /> Site cleanup Hours , <br /> Downspouls/drainage imp. Hours , <br /> Materials Backwsler valve _ __Per Unil / `_�� _ <br /> Grinder pump Per Uni�_ __ _ � <br /> Sidc sewer pipe(up to 8 feet) Fcel _ _ _ <br /> Imported Bac�ll Yards ____ <br /> Surlace Restoration Materials Lump / / �O i <br /> __�op soil, rass seed,concrete, etc. sum <br /> li Cover(irngation box or load bearing Per Unit / n U U ' <br /> cover l <br /> Renlals Speciy e�uipment Haur <br /> � __ <br /> !_ -------- - <br /> I� Fecs �isposal fees by ilem Yards � �Ly. � <br /> --- - -- --._ ', -- -_'� . <br /> --- <br /> — --- - � <br /> Delivery fees i(not covered hy abor __._____ __.---- i <br /> - -- � � <br /> --- ------- � <br /> ----- ��-�7- -- "- <br /> - - --- � -- -- --- _ _ ' <br /> Eli iblcTolal ._. � . --- �•--" <br /> Olher Costs Cosis nol associated wilh BWQ, and , <br /> not eligibie ior rebate (dclail below)__ __ _________ - <br /> - -- � <br /> --' -- -- - ---- - ��� <br /> __.__ — � -- - � <br /> r Ineligible Totai . __ � , <br /> j Total _ - --.- - -- $ - <br /> Revised 9/03/2014 � <br /> �I <br />