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�i4CKV11A�E13 PREVEIVTIOf� PROGRAM <br />�NiOOICE �O�T �REAK�OWN <br />Please use lhis invoice Cost Breakdown as a template tor invoicessubmittod as part of the Backwater <br />Prever,tion Device rebate program. L=ither lhis `orm or your ovm invoice form with the follo���ing line items can <br />be submilied. This allows you to invoice your clienl according to your existing billing template whil,e allowing <br />city slafl to idenGiy how cosls eligible for the Backv�aterPrevenlion Device Rebate were accrued. <br />Only labor and materials directly related to fhe installation and function of a backwatei prevanfion <br />device are eliglble tor Ciry rebate and there(ore should be'incfuded on the upperhalf of this ;orm. <br />Additional costs ma}� be added to bottom of the (orm. <br />5�`«,- �c, <br />8usiness Name:�'1.�jGv_!'L��'�}, �- �,SiC�� License Number. _�S���i�� <br />-f""-- <br />Business IJlailing Address: �i��%: LGc � '1 �-_ � '1� L1---L��� ----U �`�'� — <br />���y State Zip <br />Phone::�-�(O_':�`�4�-���� Email:�c {�� i ' �c?.Cl,�� � '✓ld-.S,ci�:S�c:L�'�i <br />� <br />Ad <br />Rentals <br />Fces <br />Ellgiblc Total <br />O(her Costs <br />Total <br />1 <br />Insfall <br />resloralion <br />Site c:eanup <br />pnn�nspouts / drainage imp. _ <br />Bar.k�valer vaivo <br />Grinder pump <br />Side sewer pipe (up to 8 fect)_ <br />Imported Backfdl <br />Surlace Restora!ion tJate�ials <br />(irrigation box or <br />Specify equipment <br />item --- <br />❑elivery fees d not covered by labnr <br />-. � ��- -- � �� �'1.,�- <br />Costs nol associaled �vith BN.'D, and <br />nol eligible lor rebate (delailbclow) _ <br />Revised 9/03/2014 <br />Per Unit <br />Fect � � <br />Yards <br />Lump --- — <br />sum <br />Hour <br />—� �— - --ja <br />� -- i— <br />_"_"— p� ��� � <br />_'_ __—�___ _—____1 <br />� <br />�[i�,5_���� z(r.y/�f <br />