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i BACKWATER PREVEIVTfON PROGRAM INVOICE COST BREAKDOWN Please use this Im�oice Cost Breakdown as a template for invoices submitted as pa�i of the Backwater Prevention Device rebate program. Either this form or your own invoice form with the following line items can be submitted. This allows you to invoice your client according to your existing billing template while allowing c'!y staH to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. Only labor and materials direcfly related to the insta!lation and function of a backwater prevenfion device are eligible for City rebate and therefore shoufd be included on the upper half of thls form. Additional costs may be added to 6ortom of the form. 5�'�_i�/ ._�s�2CL—� �Business Name; Pri� �t� 4�/?�i��l� License Number. � � — Business Mailing Address: o`��i.'[� LCcr"��lil Vll�-• �Lf[� �-��A 9�,�t�3 City State Zlp Phone:��L,��/C) �"�bS�-�. Emaii:(�il1 L��]m�i'��an �� 'c: �i]d S_iC�t'�t'y�Y°�/; C'c5717 Cate � Descri tion Units �uanti Rate Total Administration Adininistretion I management Hours Labor CCTV Inspection Hours � - BV�N Install Hours pipe replacement Hours Surface restoration Hours Site cleanup Hours Oownspouts/drainage imp. Hours Materisls Backwater valve Per Unit - Grinder pump Per Uni[ Side sewer pipe(u to 8 feet Feet r� �� Imported Backiill Yards Surface Resloralion Malerials Lump to soil, rass seed,concrete,etc. sum Cover(irrigalion 6ox or load bearing Per Unit � � cover — Rentals Specify equipment Hour �--rrru'�-1�=I�e�--- 3 - a�__ Fees Dispos�l fres by item Verds _ ;aT Delivery fees if not covered by labor Eli ible Total - $ Other Cosu Gosts not associated with BWD, and not eli ible for rebale delail below __ ��w . �21�;/]Ic� C0� __�j 14Z'i Nu. CIa/ --_-_�� _� ,,.��1 �,� Ineligible ToWI � Total -- � a — Revised 9/03/2014