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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a temp(afe for invoices submitted as part of the Backvrater <br />Prevention Device rebate program. Either this form or your ovan invoice form with the following line items can <br />be submilted. 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 8ackwater Prevention �evice Rebate were accrued. <br />Only /abor and materia/s directly related to the instal�afion and function of a backwaterprevention <br />device are eligible for Ciry rebate and therefore should be included on the upper half of fhis form. <br />Additional costs may be added to bottom of the fonn. <br />8usiness Name:�N7�loR�i�d��Z?� �icense Number: ��WDIJ�,S �-1 �\� _ <br />Business Mailing Address: ��a3 �6� �' ,i�� sw• CO�� �tiA �g��'6 <br />Phone:a��� � �/q3 <br />Labor <br />CCN Inspeclion <br />� BVNJ lnstall <br />Pipe replacement <br />Sudace restoretion <br />Sife cleanup <br />Downspouts / drainage imp. <br />Is Back�vatervalva <br />Grinder pump <br />Side se�ver pipe (up to 8 feet) <br />Imported Backfll <br />Surtace Restoralion Materials <br />(top soil, grass seed, concrete�etc,L <br />Cover (irrination box or load bearing <br />Rentals <br />Fees <br />Other Costs <br />Total <br />Total <br />Revised ,9;03.i2014 <br />Disposal fees by item _ _____ <br />Delivery fees if not covered by labor <br />Costs nol associated wilh BWD, and <br />not el�ible for rebate �detail below _ <br />Hours <br />Hours <br />Hours <br />Hours <br />Per Unit <br />Per Unil <br />Feet <br />Yards <br />Per lJnit I � � <br />K <br />.fcwtk /o� C�/`vn i <br />n <br />r.� <br />� � <br />---- C�'f' <br />. � i• <br />