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Backwater Nrevention Device <br />� Rebate Program PeY�,��. # �����-oiy <br />Invoice CAst Breakdown <br />Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your o�vn invoice form with the following line ilems can <br />be submitted. <br />Only labor and materials directly related to the installation and function of a backwater prevention <br />device are elig/bf� /or City re6ate and therefore shou/d be included on the upper haff of fhis form. <br />Additional costs may he added fo bottom of the (orm. <br />,%��Z LOnf�dctOrS, LLL �-1� #7.uzC6GLB"yffPR <br />Company Name: f7$3�.ko� ✓e �/� u0t' Ho3� 57-if-2oo Date: II —`�'�7 <br />Fa��sr ..rt�WA RBrgS <br />Property Address: � �� 3 Rvo{�t�a 1(� ✓�/e . EVeYe�({� W!k 9Sf 2� � <br />Category Description Units I Quantity Rate Total <br />Administration Administration / management Hours _ f Z 5� 3 SOJ <br />I_l_abor <br />� CCTV Inspection Hours � /ot /p�� <br />BWV Instail Hours Z 2G' � 5 Zh' <br />Pipe replacement Hours <br />SuAacerestoration Hours )_� 3ov 3C� <br />Sitecleanup Hours ?ou �,300 <br />Downspouls / drainage imp. Hours � <br />Materials <br />E3ackwater valve Per Unit Zco � Gb <br />Grinder pump Per Unit <br />Side sevmr pipe �uU to 8 feet) Feet �(J � vn <br />Impo�ted Backfill Yards <br />SuAace Resloration Materials Lump 1 � 2p � 2U <br />_�p soii, 9rass seed, concrete, elc. sum <br />Cover (irrigation hox or load bearing Per Unit I ���� (' S�� <br />cover -� <br />RenWls Speci(y equipment <br />___ Ci.T✓ CAP��('� � $PUF.IC fiour � �� �� � /2D _ _ <br />rFees Disposal fees by item Yards _ _�_ /p0_ /OC� <br />� --- <br />I 1 Delivery lees if not covered by labar ---- - <br />� Other J S: c��SP.� ! :ti+ 0 �3�� <br />— --- --- - - — Eligi6leTotal .�+ Z2 f3� <br />Othcr Costs Costs not asseciated with �WD, and <br />not eli ig ble (or rebale delail below _ _ <br />Incligible Total $ <br />1 subtotal _ $ z? {�� <br />- — 1 Tax (9.2%) _ $ Z� o.S� <br />— --- — -- LTotal $ 2y 9_�'�., <br />Revised 12/11/2014 <br />0 <br />