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BACKWATER PREVENTION PRLGRAM <br /> IN4�OICE COST BREAKDOWN <br /> Please use ihis Invoice Cost Breakdown as a template for invoices submiried as part of the Backwater <br /> Prevention Davice rebale program. Eitiier lhis form or your own invnice form with tha fc iowing line items can <br /> be submitted. This allows you lo invoice your client according to your existing billing template while allowing <br /> ciry staft to identify how costs eligibla for the Back�vater Preventien Device Rebate�vere accrued. <br /> Only labor and materials directly related to the installation and function cf a backwate�preven6on <br /> devlce are eligibfe for City rebate and therefore should 6e included on the upper half of thts form. <br /> Addifional costs may be added to boftom of the form. <br /> 5�`��-- LLCi � /�� <br /> Business Name:_��j�c h ��t�-�`�ir�P License Number._��J_��1�_ _ <br /> Business Mailing Address: o�ftx�c (_G3/'�cl1 __�,!L_______���-�-'g U�����3 <br /> Ciry State Zip <br /> Phone: � L> •-' .Si�. Email:�i r�� '�cz�> 'G[]n�l <i�tie,C�;�2"!: C'[>7.7 <br /> a_ _ ' <br /> C�tcy� Description Units Quanti Rate Tolzl _ <br /> Administretlon Hdminislretion/managemenl Hours _ <br /> Labor CCTV Inspection Hours _L _ _� �j,�� <br /> gINV Inslall Hours _ <br /> Pipe replacement _ Hours __ __ I <br /> Surface restoration Hours " �� - <br /> Site cleanup Hours <br /> �ownspouts!drainaye imp. Hours <br /> Materials Backwater valve _ Per Unit �� S ,"; ��-_[��y�,�_ <br /> Grinder purnp Per Unit <br /> Side sewer plpe(up to 8 teet Feel �� fd� �; ^/la ab' _ <br /> Imporled Backfill Yards ____ <br /> ' Surface Restora�ion Malerials Lump <br /> _ to soil, rg ass seed, concrele etc. sum � __ _ .�L.____�}-. <br /> Cover(irrigation box or load bearing Per Unil � 1 l� <br /> cover _ <br /> Rentals Specify equipmenl Hour _ <br /> �ti-v_i�Tr� ;,� -- _�t� 3 � � � <br /> Fees Disposal fees by item _ _ _ Yards _ ,r��� — � <br /> — O� <br /> --- — <br /> Dr.live�y fees if not covered by labor _____ _ _ <br /> Eli ible Total -T � �`� $ <br /> Other Costs Costs not associated wilh BWD, and <br /> nol eligible lor rebate(delail below _, _ <br /> -- - - —= -� - -*�-\ t�'A, <br /> ---�- �' -_ <br /> Ineligible Total — - --- - -- �----- <br /> Total _ —3— � - --- <br /> � � • �� (��` � � � rJ <br /> �,�.\ � � / <br /> Revised 9/03/201d <br />