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BACKWATER PREVENTION PROGRAM <br /> � INVOICE COST BREAKDOWN <br /> Piease 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 own invoice form wilh the following line items can <br /> be submitted. This allows you to invoice your client according to your exisling billing template while allowing <br /> city staff to identify how costs eligible icr the Backwater Prevention Device Rebale were accrued. <br /> Onlylabor and materials direetly re/ated to the installafion and function of a baer�If o�his fot�n <br /> device are eligible for City rebate and therefore should be included on the upp <br /> Addit�ona!costs may be added to bottom of the form. <br /> Sp�.l'��� <br /> , C, ' P License Number. _�5������ <br /> Bus�ness Name: 1' ' 2�t �� <br /> Business Mailing Address: r'��c �r�c����� �"�)� �`Y`���� <br /> City State Zip <br /> Phone:,�Xc•�1r� •-;aYf�a. Email:��)r)�^ ��n � 'G �L][l �'rt�C._�2'I': C<53J� <br /> Descri tion Units Quanti Rate Total <br /> Cate o HOu�s <br /> Administration Adminislration/management <br /> Labor CCTV Inspection Hours ��� <br /> gWV Install Hours <br /> Pipe replacement Hours <br /> Surface restoretion Hours <br /> Site cleanup Hours <br /> Do�vnspouts I drainage imP Hours <br /> Materials Backwater valve Per Uni� l�__�1j.� <br /> Grinder pump Per Unit <br /> Side sewer pipe (up to 8 teet) Feei � �� �f� <br /> Imported Backfill Yards __ <br /> Surface Restoration Materials Lump 3� <br /> to sp oi1,qrass seed concrete,etc.) sum <br /> Cover(irrigation box or load heanng Pcr Unit f f a � <br /> cover <br /> Rentals Specity equipment Hour <br /> c�-� �� <br /> Fees Disposal fees by item Yards �.��- <br /> Oclivery fees if nol covered by labor <br /> -- _ � <br /> Eli 161e Tota� <br /> Othcr Costs Costs nol assotialed wiih BWD,and <br /> not eli ible for rebate detail bclow — <br /> 4, C c M'�iN '�'t __ S - <br /> 11a tw <br /> � � <br /> �ncligibie Total S � r <br /> 3 bt � - <br /> Totat - <br /> R=vised 9/03/2014 <br />