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BACKWATER PREVENTION RROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a template for invoices submitled as patt of the Backwater <br /> Prevention Device rebale program. Either ihis form or your own invoice fortn with the following line items can <br /> 6e submiMed.This allows you lo invoice your client according to your existing billing template while al�owing <br /> cily stat(lo identify how costs eligible for ihe Backwaler PrevenHon Device Rebale were accrued. <br /> Only/a6or and maMrials directly related to fhe fnstallation and fl�ncdon of a backwater preventfon <br /> device are eligible lor City re6ate and therefore sAould 6e includ�^d on the upper haN o/thir lorm. <br /> Additional cosis may be added to bottom o(the lomr. <br /> Business Name:�t�- P�U�'+b�� <<<- License Number.�n�v4'!�Crl/ ,�� <br /> Business Mailing Address 1�"�CU�� U��'ttt,YLLF'YL�.� F�'� �V�'1�C- w`YQ 9 �L�1'�, <br /> City State Zip <br /> Phone:��� �l�,"�-Ol?�� Email: (tli-pl�ni l�(i'LA L( C- ��l� �'1»F�7L •L«"1 <br /> Cate9ory Descdption _ Units Quantit Rete Total <br /> Administration AdminisUa6on/managemenl _ Hours <br /> Labor CCNInsUecUon Hours _f - �o ' <br /> BVYV Install Hours U <br /> Pipe replacerr�enl _ Hours _ <br /> Surface resloralion Hours <br /> Sile cieanup Hours <br /> DownspouLs 1 drainage imp. Hours <br /> MateHats Backwaler valve Per Unit /- �O <br /> Grinder pump Per Unit _ _ <br /> Side sewer ipe up to 8 feet) Feet <br /> Impo�ted Backfill Yards 0 __ �� , <br /> Surface Restoretion Malerials Lump <br /> _ to soil, rass seed,concrele,etc.) sum <br /> Cover(i�rigalion box or load hearing Per Unil � �0 0 <br /> covcr <br /> Rentals Speci equipmenl Hour <br /> Fees Disposal fees by ilem Yards ��_ _L"LO � <br /> Delivery fees if not covered by lahor __ __ <br /> -- -- — $ - I <br /> Eli ible Total <br /> Cosls not associaled wilh BWD,and <br /> Othe�Costs not eliqitte for rebale(delail below _____ � � <br /> InelfgihleTotal $ 3� <br /> Total $ <br /> Revised 9ro3/2014 <br />