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BACKWATER PRE�/ENTION PROGRAM <br /> INVOICE COST BREAKDOWN <br /> Please use this Invoice Cost Breakdown as a temp(afe for invoices submitted as part of lha Backwater <br /> Prevention Device rebate program. Eilher this form or your own invoice form v�ilh the following line items can <br /> be submitted. This allows you to invoice your client according to your existing billing lemplate while allo�ving <br /> city staff to identify how cosis eligible for the 8ackwater Prevention Device Rebate were accrued. <br /> Only la6or and materials directly related fo the installation and function of a backwater prevention <br /> device are eligible forCity rebate and therefore shoufd be included on the uppe'r FiSlf o�this form. <br /> Addifional costs may be added to botfom ot the (omi. <br /> � ' f�s•��2 ����SS ���` ,S � <br /> Business Name:� (, o���"i �(�G License Number. <br /> BusinessMailingAddress:��.2,7 �5f�t� .S� sW C.�I�iL�S ��� ��`�� <br /> ����/J ) ,,r _City Sfate Zip <br /> Ph;,ne:�=(tj,� /I9� Email:��Iu�.S�w�G�+��S���e�(o� (�'�.i I .Co�"1 <br /> F��ate o Description Units �uantit Rate Total <br /> Administration Adminislration/management Hours _ _ <br /> Labor CCN Inspection Hours <br /> BV�N Install Hours <br /> Pipe replacement Hours O �,Q3s•OCJ <br /> Sudace resroration Hours ' <br /> Site deanup Hours __ <br /> Downspouts!drainage imp. Hours <br /> Materials Backwaler valve Per Unit _J •GC7_ � ,Op <br /> Grinder pum Per Unil <br /> Side sewer pipe(uo to 8(eelL__ Feel _ _ <br /> Imported Backfill Yards _ <br /> Sudace Restoration Malerials Lump <br /> fo soil,lrass seed, concrele,etc.) sum <br /> Cover(ir;igation box or load bearing Per Unit I ^D a� �D ;1r.� <br /> cover) Gt _ �c.�_ <br /> Rentals Speci(y equipment Hour <br /> Fees _ Disposal(ees ly itom Yards � �� ��q(� ) _ `� � -T�;I-aL <br /> Delivery fees if not covered by labor _ ��^b% �o`Z`�S�� <br /> . _ _ - —,� , - -�a0 �?� <br /> . <br /> Eli iblo ToWI _ __ $� � ' � <br /> Other Costs Costs not essocialed�vilh BWD,mid <br /> __ not eligib'__for rebale(detail 6elow) __ <br /> -- -- _ Oti �t U cc�� c v✓ <br /> -- - —'4 - � �rl �I? <br /> G�¢ un. <br /> � .�-{'/���f .tH�JL1I' <br /> _--.y.�_=_ <br /> Ineligible Total � 2 2 � <br /> Total � <br /> Revised 9/03/2014 <br />