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BACKWATER PREVENTION PROGRAM <br /> lNVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Dreakdo�vn as 2 templale for invoices submitted as part of the Backwater <br /> Prevention Device rebate prograrri. Either this form or your own invoice torm wilh lhe following line ilems can <br /> be submitled. This allows you to ir:voice your cii�nt accordin5 to your exisling billing lemplate while allowing <br /> city staff to identify how costs eligihle for the Ba�kwater Preveniion Device Rebate were accrued. <br /> Only fabor and materials directly re(ated to the installation and function of a backwaterprevention <br /> device are eligibfe for City rebate and ther�etore should be included on the upper half of this form. <br /> Additional costs may be added to bottom of the(orm. <br /> p �•, )r- / <br /> Busine�s Name:��t�uiY>e��- License Number. _ C/�ISS �'� <br /> Business Mailing Add,ess ? j�� -?�G�� S� >� �ur'�� � R��a� <br /> / /Jp I I City Stat /��� . ip <br /> Phone: ��C�7� (�15 Email:�F���u�K�'1a�� C��d ��e.� �l�"«i� �� f.oNy <br /> Cate o Descri tion Uni[s �uanti Rate Total <br /> Administration Adminisha!inn/management Hours ______ <br /> Labor CC1V Inspection Hours <br /> BNN Install Hours � <br /> Pipe replacement Hours �QO.tZ9 <br /> Surface resloration Hours <br /> 5ite cleanup Hours � <br /> Downspouts/drainage imp. Hours <br /> Materials Back�vater valve Per Unit _ 5, DO <br /> Grinder pump Per Unit <br /> Side se�ver pipe (up to 8 feel) Feet _ <br /> Imported Backfill Yards _ <br /> Surface Restoration Materials Lump � <br /> �o soil,grass seed,concrete,ela) sum ' <br /> Cov irriga ion bo r load bearing Per Unit � �� <br /> cove ' ___— <br /> Rentals SpeciFy equipment t lour <br /> -j- _ - <br /> Fees � Disposal fees by item Yards � ,/ ,�D.bO _ ��'r/ <br /> - 9-- — � <br /> Delivery fees if nol covered by labor _ _��b C �,200, oc� / <br /> _ {I `T�A X � 0 6 0 V' <br /> Eli iblc Total - - — --I-- --- -- - -- N(7 . O <br /> Other Costs I Costs nol associated with BWD,and I <br /> not el�ible far rebale(detail belo�v) _ _�� � <br /> -- --�---�— , <br /> �a � r3 � �... <br /> - — — —=�, - , <br /> — c► Ilw� ih,ba�� I <br /> IneligibleTotal $ � /ZG�S <br /> ToWI � 5 <br /> Revised 9/03/2014 <br />