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BACKWATER PREVENTION PROGRAM <br /> II�VOICE COST BREAKDOWN <br /> Please use lhis Invoice Cost Breakdown as a templete for invoices submitted as part of the Backwater <br /> Prevention Device rebate program. Either this form or your own invoice form wiih the following line items can <br /> be submitted.This allows you to invoice your client according to yaur existing billing tempiate while allowing <br /> city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br /> dev/e'e are eligible for C"ty re6a't and therefore should 6e inc uded o�n the upper�lf of this �t�n <br /> q�dntio�nal_cJ�¢may be added to bottom of the(orm5 <br /> � lN' �ttC�i��� �o <br /> �usiness Name: �^^arti�� �� ti" ' G�'S�License Number.�_5��+6'7�� - <br /> Business Md�ling Address: o��� ��l r�'� +J� �it��, Sta� 9 Z pt�� ' <br /> y �r�n .-•�nQ� Email:�'���n•;r�rr_����L]d �v�C�� Y�l' CcSril <br /> Phone:�.sZca. � <br /> Cate o Descrt tion Units Quanli Rate 7otal <br /> Administration Administratlon/management Hours <br /> Labor CCN Ins ection Hours <br /> BWV Instell Hours <br /> Pipe replacement Hours <br /> SuKace restoration Hours <br /> Sita cleanup Hours <br /> Downspouts/drainage tmp. Hours <br /> Materials Backwater vaive Per Unit {- <br /> Grinder pump Per Unil <br /> Side sewer pipe up to 8 Teet) Feet �� � ^f' <br /> Imported Bac�ll Yards <br /> Surface Restoration Materials Lump <br /> to soil rass seed concrete etc. sum <br /> Cover irrigation bo or load bearing Per Unil ` <br /> cover <br /> Rentals Specify equipment Hour <br /> Fres Disposal fees by item Yards <br /> Delivery fees if not covered by la6or <br /> EII Ible Total ` � a $ <br /> Other Cos�s Gosls not associated wilh BWD,end <br /> not eli ible tor rebate detail below <br /> I <br /> n <br /> V <br /> Inoli ible Total $ <br /> Total $ <br /> f�r� �� 2 �y <br /> Revised 9/03/2014 <br />