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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this InvOiCe Cost Bfeakdotivn as a templale iar invoices submi�ted as part of the Backwater <br /> Prevenlinn Device rebate program. Eilher this form or your own invoice Form �vilh the followir� line items can <br /> be submitted. This allows you to invoice your client according to your existing billing template while allotiving <br /> ciry staff lo id��ntify how costs eligible for the Back�.vater Prevention Device Rebate ivero accrued. <br /> Only labor and materials directly related to ttra rnstallation and(unction of a backwater prevention <br /> devlCe are eligitrle forCity rebate and therek�re should be included on tlie upper half of this form. <br /> Additional costs may be ..dded to 6ottom of the 'orm. <br /> /�b5o�u�"�. SfoW'e�. Se�2:,Z ��SOISS �"� 5 <br /> Business Name: _License Number. <br /> Business Mailing Address:���i .����� s� s�' "'��"`'��" � � ab <br /> ' � / Cly State Zip <br /> rhone: D�" C'�� ��_Email:�f�lt��°��ur� .Je �('�«c�j�,Con1 <br /> Cate o Description Units_ Quantity_ Rate Total _ <br /> Administration Adminislration l management Hours ___ <br /> Labor CCTV Inspection Hours <br /> BVJV Inslall Hours <br /> Pipe replacement Ho�rs $.Q'� � <br /> 3u:face restoration Hours � <br /> � Site cleanup Flours <br /> Do�vnspoutsldrainageimp. — Hours � _ _ � <br /> Materials Bachtivaler valve Per Unit _� aQ�.D� , <br /> Grinderpump PerUnit _ _ � <br /> Side se���er pipe(up to 8 feeQ __ Feet __ <br /> Imported Backfili Yards <br /> Suriace Rc�storalion Maleriols Lump <br /> to soll concrete,elc.1 sum <br /> Cove irrigation b or load bearin9 Per Unil ' r��� ,�-y� <br /> o� . nW <br /> cover) _ __._ <br /> Rentals Specify equipment � Hour _ --f�� � <br /> _ (C7 I <br /> . --� --- - ---- I <br /> Fees Disposal fees hy item ___Yards � �(2C� _ 'f , __ <br /> Delivery fees if not covered by labor _���S� __ <br /> - - — - --�Ax' 70'l• ° <br /> Eli ible'fotal --- — -- — � '� $ �� � <br /> Other Cosls Cosls not associaled with DWD.and <br /> nof eliqib�e for rebate(detail hcloiv � _ _ <br /> -- "— a � •y.hacFW' <br /> _ _._ _ ,�.v�ati UT ?� <br /> ---- --- - ---- a ,ti � �'^�i <br /> — — ����/���.,�{c -..br��1 I <br /> Insligible Total ' " ' b S <br /> Total � <br /> Revised 9/03i2094 <br />