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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST Bf'i�AKDOW�N <br /> Please use ihi; Invaice Coti Breakdown as a template for inwices subm'dted as part of fhe Backwater <br /> P�evention Oevice rebate program. Either this fam or your own invoice form with the following line items can <br /> be subm'itted.This allows you to invoice your dient a000rding tn your existing billing template while alEowing <br /> city slaft to identify how costs eligible for ihe Backwater Prevention D�vice Rebate were accrued. <br /> Only lebor and maMrials dltectly related to tl►e instelladon and Iunetlon o/a beekwater proventlon <br /> dsvics are mligibfe forC1 y nebate and M�ve/one should be ineludbd on Me upper heH of fhfs form. <br /> Additlonal crosfs may be added to boftom ol fhe form. <br /> Business Name:��- P�U� LL L License Numbc�r. �4f4-/�1��-�'(ll/ f�n <br /> BusinessMailingAddress: rL'�CU4( �/l��f'Ct.V2LY{'lCL Fg'11� �V.y' �� in744 9 �"L..c�; <br /> Cily State Zip <br /> Phone:�Z� ���"�—Ot2�> _Email: Gt-li- /� !ot C_ �� •�c�"'� i <br /> i <br /> Ca o Deseriptlon Un'ds Uua ' Rete TMaI _ <br /> Administration Administration/m:.nagement Houra <br /> La6or CCN Ins ection Haurs (�0�. <br /> BWVlnstall Hours — 2 ' <br /> Pipe replacer.ienl Hours <br /> Surta�mstur�tion Hours C.J <br /> Siln d�nup Hours <br /> Dawnspoutsldrainageim . Hours <br /> Mate�fals Backwater vaNe Per Unit ``j"� <br /> Grinder ump Per Unil <br /> Side sewer pipe(up to 8 feel) �� <br /> Impo�tad Backfiil Yards ' <br /> Surface Resmration Ma1c�iaL� Lump Z d� E <br /> to soil, seed,concrete,etc. sum ! <br /> Cover(rriga0on box or toad bearing Per UnR i <br /> cowr _ � <br /> ReMals Specify equipment Hour <br /> Fees Dis osal fees by itam Yards I <br /> I <br /> Delivery fees if nol covered by labor I <br /> Eli Ible Tohl � ' $ <br /> 01her Costs �not associated with BWD,and <br /> not eli 'ble for rebate(detail below)_ _ <br /> l'.r° � <br /> (��1����W ` � <br /> __� 1 <br /> k <br /> �_--- � � �- � <br /> Ineligible Total � �� t:tit S <br /> Total $ �/ <br /> �P �� L ✓ <br /> � �b ��,� � " <br /> Revised 9/fll?2014 <br />