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t <br /> I <br /> ieJ�PV�A�6l� Y Ib�1Y Y ��� �7 6�iG tl ��� ��O�i `I�V�60 I <br /> E� B�li9�9�� C���' ���:s�&C�1�1�9N ; <br /> ; <br /> Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backvaater � <br /> Prevention Device rebate program. Eiiher this form or your own invoice form �vith the following line items can <br /> be submitted. This allows you to invoice your client according to your existing billing lemplate�vhile allo,�ing <br /> city staff to identify hotv costs eligible for the Backv�ater Prevention Devico Rebate were accrued. , <br /> t <br /> Only labor and materials directly refafed to the installation and function of a backwa(er prevention � <br /> � <br /> device are eligi6le for Ciry rebate and fherefore should be included on the upper fialf of this form. � <br /> Additionaf costs may be adaed fo bottom of the torm. ' <br /> � � U� �v l <br /> Business Name;�.(-u'�zr'� ��`+�'�� L` -_ �,r1P License Number _(��J�i��J :. <br /> Business Mailing Address: oZ(�r'.�-�i�' LL'���_!������ ���� U�`��'3 ' <br /> City State Zip i <br /> � Phone:,���.�/c� �'�iS�� [mail:��n n1zn�_Gr�nrj 4ir;��.N,,2'.r. C�c71? i <br /> Units Quanti Rate Totai � <br /> Catc�� �escri tion - �- <br /> Administretion Hdministration/management Flours i <br /> Labor CCTV Inspeclion Hours � - �� � <br /> gWV Install Hours <br /> Pipe replacement Hours � <br /> � Surface restorelion Hours �� . _ � <br /> Site cleanup Hours <br /> �ownspouts I drainage imp. Hours ; <br /> Materiais Backwater valve Per Unit �,[���(� c�� ' <br /> Grinder pump Per Unit � <br /> Side se�ver pipe(up to 8 feet) Fee[ �' '� <br /> � <br /> Imported Backfll Yards _ ____ i <br /> Surface Resloretion (vlaterials Lump � ; <br /> to soii, rass seed, concrete.etc. sum c�J ^ (�__ i <br /> Cover(irrigation boz or load 6earing Per Unit � 1 � � ; <br /> cover _ ! <br /> Rentals Specify equipment Hour _ _ % <br /> '�t�ec` N P ---- �_._ `�, _ ' <br /> --- : <br /> Fees Disposal fees by item Yards ____ — � <br /> — —�- t <br /> Detivery fees if nol covereA by labor ______ _ <br /> — i <br /> Eli ible Total � � � � � � <br /> � <br /> Othcr Costs Cosls not associated veith BWD, and i <br /> nol eli ible for rebale delail below� ___ ___ � <br /> i <br /> ' '_"_ I <br /> I <br /> i <br /> Ineligible Total $ ; <br /> � Total _ $ ' � `• <br /> -- _---- <br /> i <br /> 1 <br /> ; <br /> Revised 9/03/2014 • ! <br /> i <br /> , <br />