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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 with 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 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 />5�-� er-. Lr'c" <br />Business Name: �l(rztZ,Ta ��P /License Number. _Q5 •`� <br />Business Mailing Address: a� LGtTliV1 Y / l� �l -t d l 1)� U RJr�3 <br />City State Zip <br />n (r n Grtry rcr Cr, <br />Phone:�p-•�!> �,:ar�� Email:is � 1nAt�r_____�_i�cZ <br />Cate o _ <br />Administration <br />Descri tion <br />Administration I management <br />Units <br />Hours <br />uanti <br />Rate <br />Total _ <br />_ <br />Labor <br />CCTV Inspection <br />Hours <br />_ <br />FWV Install <br />_ <br />Pipe replacement Surface restoration <br />Site cleanup <br />Downspouts I drainage imp. <br />!-9 <br />Materials <br />Backwater valve <br />Grinder pump Side sewer pipe (up to 8 feet) <br />— <br />_ <br />Rentals <br />imported Backfill <br />Surface Restoration Materials <br />(top soil grass seed, concrete, etc.) <br />Cover (irrigation box or load bearing <br />cover) <br />Specify equipment <br />Yards <br />Lump <br />sum <br />Per Unit <br />Hour <br />3 (i <br />—� <br />Fees <br />Disposal fees by itmn <br />Yards <br />Dolivery fees if not covered by labor <br />_ <br />--- <br />_ <br />< <br />$ f—r <br />Eli ible Total <br />Other Costs <br />Costs noD, and <br />t associated whit BW <br />not eli ibl9 a for rebate detail below <br />'$ <br />Ineligible Total <br />Total <br />tu�q <br />14 $ <br />Revised 9/03/2014 <br />