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BACKWATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdowi i as a template for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your own invoice form �vith the following line ilems can <br />be submitted. This allows you lo invoice your client according to your existing billing templale while ailowinq <br />city staff to identify how costs eligible for Ihe Bacicwater Prevention Devlce Rebate were accrued. <br />Only la6or and materials directly related to the installation and funcflon o/a 6eckwater prevention <br />device are eligi6le tor City rebate and therefore should 6e included on the upper half of this form. <br />Additional costs may be added to bottom of the form. <br />Business Name: ��i- P��%1��1 ✓!u l-! C License Number: A�-�' h'�U l�l) %/Pl��_ <br />- � — �— • - - r' <br />Business Maili�g Address: <br />9 <br />Phone: �5`�-��%—O(Z � Email: !i�/4-P��N��/!%�9/(f oZ��"'���'��teL��'�"L� <br />Revised 9/0312014 <br />� <br />