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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdovm as a template for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your ow� invoice form with the foliowing line items can <br />be submitted. Tliis allo�vs �•ou to invoice your client according to your existing billing template while allowing <br />city staff to identrfy how cosis eiigible for Ihe Backv�ater Prevention Device Rebate �vere accrued. <br />Only labor and materials directly related to the installation and function o/ a backwater prevention <br />device are eligible fo► City rebate and therefore should 6e included on the upper half of this form. <br />Additionai costs may be added to bottom ot �I�e form. <br />5��>�^ , �-�c' � j�� <br />Business Name:�(`����i� �r'�'+1_ ��iP License Number: : ^ <br />Business Mailinc� Address: oS(!:L(c LFrc (�l�l�l �,�t�-' ��V�%��� � �=L+ ' ""• „' <br />City State Zip <br />Phone: �'��v'"�2t� Email:_�,i�_C1t}k:l'i�s:��i�GLr]�l-.5-;ci�t%1.�'(: C'c� <br />Revised 9/03/2014 <br />