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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your own invoice form wifh the following line items can <br />be submitted. This allows you to invoice your client according to your existing billing template while allowing <br />city staff to identify how costs eligible for the Backwater Prevention Device Rebale were accrued. <br />Only /a6or and materlals directty related to the Installation and lunction of a backwater prevention <br />devlce are e�rqible for Clty rebate and therelore should 6e included on the upper haf/ oi this lorm. <br />Additionaf costs may be added to bottom o/!he (orm. <br />eusiness Name: -�l.-r!'I L�I l�-H �.�— License Number. _�9-O�v t� L1 // P�� _ <br />Business Mailing Address: �U �� V! f'ti�-K1 N"�ri- !�_ 7`�2 T�� 9'� �� <br />�._ <br />Phone: -1Z-� � � `r-�(L�� <br />Lebor <br />Materials <br />S�� <br />R U�'L"`ti'�. <br />Fecs <br />Ellgiblc Totn <br />Othcr Costs <br />Tafel <br />Total <br />Administralion I <br />CCN Inspectic <br />Sufiace restoralion <br />Site cleanup <br />Dawnspouls I drainage ii <br />Backwater valve <br />Grinder pump <br />Side sewer pipe (up to 8 <br />Cover (irriga6on box or ioaa <br />cover <br />�eciry equipment <br />Disposal fces by item _ <br />Deliverv fees H not covered <br />Hours <br />Hours <br />Hours <br />Per Unit <br />�) Feet <br />Yards <br />Is Lump , <br />te, etc. sum � <br />bearing Per Unil � <br />Hour <br />__ — � <br />Yards <br />Costs not associated with BWD, <br />not elipible for rebate (detail bel� <br />Revised 9/03/2014 <br />/GD <br />(p O <br />5 <br />S <br />