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BACKWATER PR�VENTION PROGRi4M <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 fortn with the following line items can <br /> be submitted. This allows you to invoice your client according to your existing billing template while aliowing <br /> city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> Only labor and materia/s d(rectJy related to fhe installa6on and function of a backwater prevention <br /> device are eliglb/e/or City rebate and therefore should be incluJed on the upper half of Nrls fo►m. <br /> Addi6onal costs may be added to bottom of the(orm. <br /> Business Name:l"I�u� oRN Gc� �p,�LR _ License Number.► '"�"ss 6���� <br /> BusinessMailingAddress: 7 1� �+��fh ✓� s�, �r�°��s �R UD� <br /> , �/�� � L City State ,/ �� <br /> Phone: 2f.�— y6S" y�G�i Email:/'t�"/�%1�7e-�RH avu�� �,�qaA• <br /> Cate o DescN tion Units �uantl Rate Total <br /> Administration Adminislralion/mana ement Hours <br /> Labor CCN InspecGon Hours .6 <br /> BWV Install Houre 16/S�a <br /> Pipe replacement Hours <br /> Surface restoration Hours <br /> SHe cleanup Hours <br /> Downspouts I drainage imp. Hours <br /> Matedals Backwaterv :e PerUnil QD <br /> Grinder pump Per Unit ' <br /> Side sewei prae(up to B feet) Feet <br /> Imported Backfili Yards <br /> Surface Restoralion Malerials lump <br /> to soil, rass seed,concrete,etc. sum <br /> Cover(irrigation box or load bearing Per Unit ( '�Bv <br /> cover <br /> Rentals Speciy equipment Hour <br /> Fees Dis osal tees by ilem Yards �a • <br /> Delivery fees R not covered by labor <br /> R� _. <br /> Eli ibk Total $� 0.C 19'�,� <br /> Other Costs Costs not essociated wilh BWD,and ,f_I_� ,Z�y�,� <br /> nol eti ible for rebate detail below �'� <br /> U <br /> V ' . _ <br /> Ineli ible Total �'� $ <br /> Total $ � � <br /> � n <br /> Revised 9/03/2014 , <br />