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BACKW�►TE�� PREVENTION PROCRAM � <br /> INVOICE ��05T BREAKDOWN ' <br /> i <br /> . ; <br /> Please use this Invoice Cosl Breakdown as a template for invoices submitted as part ot lhe Qackwaler <br /> Prevention Device rebale program. Either this form or your ovm invoice for�n wilh the (ollowing line items can � <br /> be submitled. This allows you lo im�oice your clienl according to y�ur existing billing tempiate while allowing <br /> city sta8 to identify ho�v cosls eligible for the Backwater Prevention Device Rebate were accrued. ; <br /> I <br /> Only labor and materials directly ielafed to the installation and lunction of a backwater prevention ; <br /> device are eligible lor City rebate and there/ore should be included on the upper ha!l o(this (orm. j <br /> Additional costs may be added fo boftom o�fhe lo�m. j <br /> Busines; Name: }��J UiZ�1�`y u-�- License Number. _�}���� O!I PQ__ <br /> � <br /> `/ y �j,� ; <br /> Business Mailing Address' __��� G�1�'� �J�rd �l'� '�."��'�'T 9'1�'1't'j � <br /> City Statg ip ' <br /> Phone: <<Z;j L-I ��VIZ3 _Email: j'�i�Unn_ ���-L-L �'-�T � �S'7r>1Rf'� •Lp�-� ; <br /> � <br /> Category Descnption _� UnitS _ Duantit Rate Total __ i <br /> Administralion� Administrationlmanagement Hours _ _ I <br /> Labor CCTV Inspeclion Hours �d _ <br /> 8�lJVlnslall Hours � 'ZS� __ i <br /> Pipe replacement � Hours / _ <br /> Surface restoralion Ftours / �f _ _ j <br /> Site c!eanup Hours / o �D <br /> Dovmspouts/drainage imp. Hours _ ____ __ i <br /> Materials Backwaler valve � Per Unit � <br /> ; �y <br /> Grinder pump Per Unil � <br /> Side sewer pipe(up to 8 fcet) Feet / f �G7 <br /> Imported Backlill Yards _ ; <br /> Surface Resloralion Malerials Lump � <br /> lo soil, rass seed,concrete, etc.)__ sum ___ <br /> � — Cover (irrigation box or load bearing Per Unit � <br /> cover) ____ — <br /> Renlals Specity equipment _ Hour _ _ <br /> —�-j.��"�j�- --- -- - -— - �—_ ; <br /> � _ , <br /> Fees Disr,osa!fees by ilem Yards __ __ ! <br /> -- --— ---- — <br /> ----- -__ _ __ -- _ - --i , <br /> Delivcry Ices il nol covered by labor __. __ i <br /> — --- �— <br /> --- — -- ----- _ ---- -----y— -`Z_7_} � <br /> Eli ible Tolal <br /> � Othc-Casls Cosls not associaled wilh BWD, and � <br /> not e6 ib�e for rebate detail below __ _ ___ _____ _ . <br /> — -- -- <br /> -- — — <br /> --- — '� fl I <br /> — — -� _r � <br /> — --- -- I <br /> - — � <br /> —— _ Q t <br /> IneligibleTotal 5 �� • <br /> Tolal . _— --_ � � <br /> —�-- - - — - -- i <br /> I <br /> � i <br /> Revised 9/03/2074 j <br /> ' I <br /> � <br /> I <br />