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, . ga. 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. t <br /> Business Name: mg'Nivr boi Le_ License Number: 10tjt L6('/P6 <br /> Business Mailing Address: (/ tDi°LS 7C .i l p '. .&i` — wiA 9 CZ (56 <br /> City State Zip <br /> Phone:4 4 got-0(73 Email: > Pk .L VI LZC D i(7 orY'tIt1. .0 -1". <br /> Category Description Units Quantity Rate Total <br /> Administration Administration/management Hours <br /> Labor CCTV Inspection Hours <3 e' 2 G)--0 <br /> BWV Install Hours f 2 j1% f7_ S <br /> Pipe replacement Hours <br /> Surface restoration Hours ? S "2___S-- <br /> Site cleanup Hours / cZ- / cj .D <br /> Downspouts/drainage imp. Hours <br /> Materials Backwater valve Per Unit fj _) <br /> Grinder pump Per Unit <br /> Side sewer pipe(up to 8 feet) Feet <br /> Imported Backfill Yards <br /> Surface Restoration Materials Lump 2-5— 7- 5— <br /> (top soil,grass seed,concrete, etc.) sum <br /> Cover(irrigation box or load bearing Per Unit -� —ILD <br /> cover) '� �—° <br /> Rentals Specify equipment Hour <br /> Fees Disposal fees by item Yards <br /> Delivery fees if not covered by labor <br /> 7714- �_ <br /> Eligible Total $ � i <br /> Other Costs Costs not associated with BWD, and <br /> not eligible for rebate(detail below) <br /> Ineligible Total $ gall: <br /> Total $,L <br /> Revised 9/03/2014 <br />