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BACKWATER PREVENTION PROGRAM <br /> d INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a templatF for invoices submiqed as part of the Back�vater <br /> Prevention Device rebale program. Eilher this form er your own invoice form ti•�ith the following line items can <br /> be submilted. This allows you to invoice yc ur client�iccording to your exisling billing template while allowing <br /> city staN to identify how costs eligible for tl � Backvi;,ter Prevention Device Rebate�vere accrued. <br /> Only labor and materials directly re/ated to the installat.`on and/uncfior of a backwater prevention <br /> device are eligible for Ciry rebate and therelore shoufd br �ncluded un the upper half of thls form. <br /> Additional costs may be added to bottom o(ffie Jorm. ��, <br /> � �,--. 1 e L e s Number. �J. `� _ <br /> BusinessName:A?1���.�_—��'�._���5 � —��� -- - — <br /> Business Mailing Address: oj�i�o LGc�`i f�__V'11�• —f_�/'�`��--�� ����'j— <br /> City State Zip <br /> Phone:�`.�10_�Si� _ Ernail:C��O..[l�Cfltc�Ll���i�lt�11 S�Ci�'_�N��N�: �'�� <br /> Cateyory Descr: tion Units Quanti Rate Total <br /> Administration A�',ninisiration I management Hours <br /> Labor �CTV Inspeclion Hours _l_ ��Z� _�� <br /> gVtN Install Hours _ <br /> Pipe replacement Hours _ I <br /> Sudace restoration Hours i� ��J <br /> — Hours —{ � <br /> Site cleanup � <br /> Do�vnspouts/drainage imp. Hours <br /> Materiais Backwalervalve PerUnil - �"� _ _ <br /> Grinder pump Per Unil _ <br /> Side se�ver pipe (up to B feet) Fee� "�- � � �_ <br /> Imported Backfill Yards <br /> Surface Resloralion Materials lump �"v <br /> ��p sn;1,grass seed�eoncrete, etc. sum �____IU �� <br /> Cover(ungation box or load bearing Per Unit <br /> coverl—_---- — —�__ —.�-��-- �� <br /> Ren!als Speci(y equipmenl Hour <br /> - ,��;,,u_-�-��c-�-_ a�f�.--� ��--��-<�- <br /> Foes DisPo^,al(ecs by item ____ Yards _ ___ ' . _ __ <br /> -- <br /> — -- ---' � --- --- �-'---_ __. <br /> Delivery fees if not covcred by labor ___ ___._ ._ ._ ___ _ _.__. .. .._ - <br /> -- ---- - -- - - <br /> -- ___— - --- -- ---- � <br /> Eli ible 7otal � <br /> Othcr Costs osi: nol associAted v�ith BWD,and <br /> nol elipible tor rebale (delail bcloe�L_ __ ____ ___ __ _ ._.__ <br /> -- --�j-1� -tv 4oiw1 -«_� ��_- -- <br /> -�-�ci$5—g-c�y��+� <br /> Ineligible Total <br /> � -i�� -- y <br /> Total � ^ <br /> i_�—. � �i( G��T'!+- - <br /> y/��IS <br /> Revised 9/03/2014 <br /> � <br />