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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as s template for invoices submitted as part of the Backwater <br />Prevention Devine rebate program. Either this form or your own invoice form with the following line items con <br />be submitted. This allows you to invoice your client according t-j your existing billing template while allowing <br />city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only labor and materials directly related to the installation and function of a backwater prevention <br />device are eligible for City rebate and therefore should be included on the upper half of this form. <br />Additional costs may be added to bottom of the form. <br />ti✓ c1°(' L,Lx:, <br />Business Name:i Ce�,L) �SLicensee Number: <br />Business Mailing Address: <br />State Zip <br />Phone:'. ICE ' S-�l EmaiL•��)(1 _ rccz�� c dp.ta;rc( C'.SYJ) <br />tit <br />IMaterials I Backwater valve Leruntt I(Y(j ft ICtI'h'I�cC I aJ_6_� <br />Side sewer pipe (up to 6 feet) I reel tj t <br />Imoorted Backfill I Yards <br />box or <br />fees if not covered <br />Other Costs <br />Costs not associated with BWD, and <br />1v� <br />Total <br />Revised 9/03/2014 <br />