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� BACKWATER PREVENTION PROGRANI <br /> � INVOICE COST BREAKDOWN <br /> Please use this in�:.;c� Cost Breakdown as a templale for invoices submitted as pai t of ihe Dack�vater <br /> P�evention Device rebate program. Either ihis form or your own invoice form with the foliowing line items can <br /> be submitted. This allows you to invoice your client according to your existing billing template v�hile allowing <br /> city staff to identify ho�v cosis ehgible for ihe Backwater Prevention Device Rebate were accrued. <br /> Only labor and materials directly related to the fnstalla6on and fancfion of a backwater prevention <br /> devlce are eligible for Ciry re6ate and iherefore should be included on the upper half of this form. <br /> Additionaf cosfs may be added to boftom of the(orm. <br /> �1',5����';•L�' %., <br /> !3usiness Name:,�,��.(rr��`9��License Number. _�� �� <br /> 13usiness Mailing Address: iT�C-<c- LCc("�cl�l M./�����.'t.i (sl_�}�`3 <br /> City State Zip <br /> Phone:,��p'•�lc� �,�,�- -- [.mail_�J��l�9Cf_'i�?nSS�JH�iGr.)nij�;���4r�;� •C'�' c'c5?'n <br /> Cate o Description Units Quanti Rate Total <br /> Administration Admmistration/management Hours _ <br /> La6or CGTV Inspeclion Hours � <br /> gWV Install Hours <br /> Pipe replacemenl Hours _ <br /> Sudaco rest�ralion Hours _ _ <br /> Site cleanup Hours � �a <br /> Downspouls I drainage �mp. Hours <br /> Materials Dackwater valve Per Unit � ' �� _p� <br /> Grinder pump Per Unit � <br /> Side sewer pipe(up to A feet Feet � ' p`�G�=a,� - � <br /> Imported Dackfill Yards <br /> Surface Rr.storalion Maleri�ls Lump � <br /> _ Lp�oil qiass seed, roncrete.etc.L sum _�__ O— �-� <br /> Cover(irrigation box or load bearing Per Unil I � <br /> cover) _ —! �-�'_ � <br /> Rentals Specify equipmeM Hour <br /> - —���—����� —�— -�—� _� � <br /> Fees -- Disposal fces 6y i�em ---- Y�rds --- ac�,�` <br /> Dclivery fecs if not coverecl by IaUnr ____— —_ .. <br /> Eli ible Tolal --- --- — $ -- .c <br /> Olher Costs Cosls nol associaiecl with DWD,and <br /> nol eligible for rebale(delail beiow)__ _ _ --- — <br /> --- - <br /> , ---- .11�.-�°--K' �"`°Iw"r' k.w-�— / <br /> —— — — --_ <br /> --- -- --- ---- — _ ��`�-- - •--- <br /> k"''�'��--- <br /> —_--- —__ _'r}�cc�-�. . <br /> Ineligibla Total � <br /> Total -- — �a_�3�� <br /> Rovised 9/03/2014 <br />