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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 (ortn or your own invoice form with the following line items can <br /> be submitted.This allows you to invoice your clienl according to your existing billing template while ailowing <br /> city staff to identify how costs eligible for the Backwater Prevention Device Rebate w�re accrued. <br /> Only labor and materials directly related to the insta!lafion and function ofa l�ackwater prevention <br /> device are eligibfe for City rebate and therefore should be included on the upper half of this form. <br /> Additional costs may be added fo bottom o(the �ortn. <br /> Spcc�r'.�Lc:: <br /> Business Name: 1P �.U�i�������1e License Number: _���j�� <br /> BusinessMailingAddress: o��Cz.�c LGt.C�it�t IJ�E-- F(fr��1'N_�`r 1.(�� ����L13 <br /> City State Zip <br /> Phone:�Xu'�/C� '"��._ Email:�����m�rir�t�� '� 'ciP�e,-��l: C'CiYYI <br /> Cate o Descrt tton Units Quantity Rate Totai <br /> Administration Administration/management _ Hours <br /> labor CCTV Inspection Hours � __ �,� �S^tJ <br /> BVW Install HourS <br /> Pipe replacement Hours � _r <br /> Surface restoralion Hours <br /> Site cieanup Hours <br /> Dou�nspouts/drainage imp. tiours <br /> Materials BacMvater valve Per Unit �' � <br /> Grinder pump Per Unit <br /> Side sev�er pine (up to 8 fzet), Feet �� �� � �'a � <br /> Imported 8ackfill Yards <br /> Surface Reslorafion hlaleriols Lump �� 3� <br /> (o soil,grass seed, concrete, etc. sum , <br /> Cover(irtigation box or load bearing Per Unil <br /> ����, a la <br /> Rentals Specify equipment Hour <br /> �u1i-SCG�� � — -- ---- `--- �' U <br /> Feos Di^posal fee�by item Yards _ � <br /> — — --- — /�— <br /> Delrvery Iees if not covered by Inbor _____ _ <br /> Eli ible Total � $ <br /> Other Costs Costs r,ot e�ssociated with BWD,and <br /> not eli iLle for rebate detail below) ___ _ <br /> -b��'—��—�--- _� - -� -- --- - <br /> —��-a--3- . . <br /> TL4-� � - <br /> Ineligible Tofal � I <br /> Total ------- fc. � --- $ ' j <br /> IZ./f`1 /�`� � <br /> Revised 9/03/2014 � <br />