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� BACKWA�ER PREVEMTION PROGRAM <br />iNVOICE COS� BREAKDOWN <br />Please use lhis invoice Cost Breakdo�vn as a ten•elate for invoices submitted as part of the Back�vater <br />Prevenlion Device rebale program. Either this form or your own invoice form wilh ihe following line items can <br />be submitled This allows you to invoice your clieni according to your existing billing template whilc allowing <br />city staN to idenhiy hov� cosfs cligible for the Backv:aler Prevenlion Device Rebate r�err. accrued. <br />Only labor and materials directfy related to the installation and funciion of a backwate� prevention <br />device are elrgible (or Ciry rebate and therefore shoufd be included on the opper half of this form. <br />Addi(ional costs may be added (o boflorn o/the (orm. <br />S,,ti�u.�;. LLG <br />•8usiness Name:�'►'��(�_;.�ieL�_a_ ' �-�.�1C�n License Number: __pr7�' � �____..-- <br />Eiusiness tv�aiiing Address: ��rX-�c LGc[l�'t r�t�' —J--�1'� —u-�� �`�`��,`3 — <br />City State Zip <br />Phone:��/<�_��,��'�. Email_�_ �i ��,C���z��}ic�G#���`iid�bP�cC'LS�� <br />Labor <br />Matcrials <br />�__ <br />IRentals <br />;- - <br />i _� <br />Fces <br />`—_ --- <br />� <br />�- <br />Othcr Cosls <br />Ineligible Total <br />CCTV Inspc <br />Al4N Install <br />Sur`ace resloralion <br />Sile cleanup <br />Dr.wnsFouts I drainage ii <br />f3ackwaler valve <br />Grindcr pump <br />Side se�ver pipe (up to 8 <br />Imported �ackfill <br />Surtar.c Restoration Idat <br />Cover (irrigation box or load bearmg <br />cover _ _ <br />Sper.ify equipmenl <br />=r'Fc3,c_-��� - <br />Dispo:;ol fcec; 6y dc�n._ -__ — <br />Delivery fer.s if not covered by tabor_ <br />-; ,,,;�i rni : ��a - - <br />Costs not assor.iated wilh E31ND, and <br />not cligible for rebatc_(dclail below) _ <br />Revised 9/03/201�? <br />u <br />110Uf5 <br />Per Unit <br />Per Unit <br />Yards <br />l ump-- <br />sum <br />Pcr Unit <br />our_ <br />— — ' � <br />-- -- - —��. EiI---K� <br />/ - - <br />- �-a.� �- <br />