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BACKWATER PREVENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use ihis Invoice Cost Breakdown as a template for invoices submitted as part oi the Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form with the following line items can <br /> be submitted. This allows you to invoice your client according to your existing billiny lemplate while allowing <br /> ciYy staft to identify how costs eligible for the Backviater Prevention Device Rebate were accrued. <br /> Only labor and materials directly related to the installation and function of a backwaterprevenGon <br /> device are eligible for Ciry rebate and therefore should be incfuded on the upper half of tFrls form. <br /> Additional costs may ba adde�l to bottom of the (orm. <br /> �'E'�CC'�i�i c� <br /> �usiness Name:�r'ri«,.=_i� � C.�-.Z��License Number: _Qs��•� <br /> Business �vlailina Address: ��r-�c L.G[.�c�'t V'J��-_!��'��'� ���A U�����3 <br /> City State Zip <br /> Phone:�,(P'�/c�':� Email:_ • c� �r'�� n��l��.ud�'C;=;,Yl: Cxt?� <br /> Cate o Deseri tion Units �uanti Rate Total <br /> Administration Administration/management Hours <br /> Labor CCTV Inspection Hours �,Ct� I �C7� <br /> gWV Insfall Hours � <br /> Pipe replacemenl Hours <br /> Sur`ace restoration � Hours <br /> Site cieanup Hours <br /> Do�vnsoouts I drainage imp. Hours _� <br /> Malerials Backtivater valve Per Unit �L�,3 � <br /> Grinder pump Per Unil <br /> Side sewer pipe(up to 8 Teei) Feet 1� �� _,� <br /> Imported Backfill Yards <br /> Surtacc Resloration Materi�ls Lump <br /> to so�l, rass seed, concrete,etc. sum a(� <br /> Cover(irrigation box or loatl bearing Per Unil <br /> cover _� �e� <br /> Rentals Speci(y equipment Hour <br /> (e(' �k �P �? '�— <br /> Fees Disposal fecs by item Yards _ �' a�.� <br /> Delivery fees if not covered by labor __ _ <br /> Eli ible Total a- � 5 <br /> Other Casts Cosis nol associated wilh DV�ID,and <br /> nol eligible for rebate(delail Uelow <br /> . Po c�u.K�✓ <br /> — —�'*�a�'t'^'.U�91] <br /> _' ,»�u.0 �a�(rr <br /> Ineligible Total � <br /> Totai $ - <br /> Revised 9/03/2014 <br />